Faculty Bibliography

BACKGROUND: Chemoradiotherapy is an established strategy for organ preservation in head-neck cancer. These protocols are associated with added toxicity and need support infrastructure. Practice setup and availability of resources vary at the community level in developing countries. AIM: To evaluate the feasibility of organ-preservation strategies in different settings in developing countries. SETTINGS AND DESIGN: Survey. MATERIALS AND METHODS: In a questionnaire-based study, questions were directed to clinicians with varied practice setups to gather information regarding infrastructure, finance, and feasibility of organ-preservation protocols and their current practice trends. STATISTICAL ANALYSIS: Descriptive. RESULTS: Responses from 100 clinicians with focused practice in head-neck oncology were analyzed. Sixty-one percent clinicians were practicing organ preservation for advanced head-neck cancers in their practice. However, 65% centers lacked sufficient infrastructure to support organ-preservation protocols. Forty percent patients were treated on cobalt-radiotherapy machine. Fifty-nine percent of clinicians suggested that less than third of their patients were fit to undergo chemoradiation and 67% believed that adherence to treatment protocol was observed in less than two-thirds of cases. Based on their experience 82% clinicians felt that only one-third patients requiring salvage would actually undergo treatment. The majority of the patients (68%) used personal funds for treatment and less than one-third of the patients could afford complete treatment. CONCLUSIONS: The infrastructure needed to support organ-preservation protocols varies significantly between centers in developing countries. It may not be feasible to perform organ-preservation strategies in certain centers and feasibility guidelines should be made for their judicious use in developing countries.

OBJECTIVE: There have been 283 cases of meningitis after cochlear implantation reported since 2002 to the CDC Database Manufacturer and User Facility Device Experience, resulting in 30 fatalities. This is the latest of a number of reports to track the continuing problem of meningitis occurring in cochlear implant users, mainly children. RESULTS: Although a number of these patients had received a device with a 2-piece electrode, the withdrawal of that particular device has not prevented further cases from occurring. There are many potential etiologic factors potentially involved in postimplantation bacterial meningitis; although some can be managed or eliminated, vaccination against the most prevalent causal organism, the streptococcus pneumoniae, seems to be a powerful tool against this uncommon but serious complication of cochlear implantation. CONCLUSION: Although up to 20 new cases of post-cochlear implantation meningitis continue to occur annually worldwide, considering the number of new devices implanted each year, it is expected that the incidence of this complication seems to be diminishing

HYPOTHESIS: Reactivation of herpes simplex virus type 1 (HSV-1) in geniculate ganglion neurons (GGNs) is an etiologic mechanism of Bell's palsy (BP) and delayed facial palsy (DFP) after otologic surgery. BACKGROUND: Several clinical studies, including temporal bone studies, antibody, titers, and intraoperative studies, suggest that reactivation of HSV-1 from latently infected GGNs may lead to both BP and DFP. However, it is difficult to study these processes in humans or live animals. METHODS: Primary cultures of GGNs were latently infected with Patton strain HSV-1 expressing a green fluorescent protein-late lytic gene chimera. Four days later, these cultures were treated with trichostatin A (TSA), a known chemical reactivator of HSV-1 in other neurons. Cultures were monitored daily by fluorescent microscopy. Titers of media from lytic, latent, and latent/TSA treated GGN cultures were obtained using plaque assays on Vero cells. RNA was harvested from latently infected GGN cultures and examined for the presence of viral transcripts using reverse transcription-polymerase chain reaction. RESULTS: Latently infected GGN cultures displayed latency-associated transcripts only, whereas lytically infected and reactivated latent cultures produced other viral transcripts, as well. The GGN cultures displayed a reactivation rate of 65% after treatment with TSA. Media from latently infected cultures contained no detectable infectious HSV-1, whereas infectious virus was observed in both lytically and latently infected/TSA-treated culture media. CONCLUSION: We have shown that cultured GGNs can be latently infected with HSV-1, and HSV-1 in these latently infected neurons can be reactivated using TSA, yielding infectious virus. These results have implications for the cause of both BP and DFP

Reconstruction of maxillectomy with extensive orbital rim and floor excision defects is a challenging problem. The goal of reconstruction here is to provide adequate orbital support to prevent enophthalmos and diplopia as well as obturation of the palatal defect. The existing methods of the reconstruction fail to simultaneously address these 2 goals of reconstruction. A new method of reconstruction of these defects using tensor fascia lata-iliac crest flap was used in 7 cases of cancers of the maxilla, which necessitated extensive resection of the orbital floor along with the maxillectomy. The flap was raised as a muscle and bone flap in 5 cases and in 2, a skin paddle was included. The immediate and delayed outcome at 6-month follow-up was analyzed. The functional outcome with regards to the ocular position and function, palatal obturation, speech, and swallowing were recorded. The bone viability at 6 months was assessed by computed tomography scan. The flap was successful in all the 7 cases. The delayed outcome assessment showed that the orbital support was excellent with no diplopia in all the cases. The palatal defect could be covered successfully in all the cases, resulting in normal speech and swallowing. The computed tomography scan showed excellent integration of the bone. The free tensor fascia lata-iliac crest flap is a reliable and safe method of reconstruction of the orbitomaxillary defects, addressing the issues of both orbital support and palatal obturation.

OBJECTIVES/HYPOTHESIS: To analyze existing evidence regarding utility of laryngeal electromyography (LEMG) for prognosis in cases of vocal fold palsy (VFP). STUDY DESIGN: Meta-analysis of studies reporting LEMG results and clinical outcomes in 503 patients with of VFP identified by literature search. METHODS: Studies were identified by literature search. Method of diagnosis, interval to LEMG, criteria for prognostication, and outcome were assessed. Criteria for prognosis were standardized to the extent possible across all studies, and studies were checked for consistency in outcome measures and assessments. Pooled data were subjected to statistical analysis. RESULTS: A total of 296/503 patients (58.8%) had findings predictive with poor prognosis, whereas 207/503 (41.2%) had findings of recovery. According to laryngoscopic examination, 269/296 patients with predicted poor recovery had poor recovery (positive predictive value = 90.9%), whereas 27/296 (9.1%) had good recovery. In patients with findings consistent with recovery, 115/207 (negative predictive value = 55.6%) noted return of motion, whereas 88/207 (44.4%) did not. The odds ratio was 11.56 with 95% confidence interval of 7.10-18.81. CONCLUSIONS: LEMG is a good predictor of poor recovery in patients with VFP and is clinically useful in identifying candidates for early definitive intervention

OBJECTIVES: To determine the efficacy of cochlear implantation (CI) in prelingually deafened adolescent children and to evaluate predictive variables for successful outcomes. DESIGN: Retrospective medical record review. PARTICIPANTS: Children aged 10 to 17 years with prelingual hearing loss (mean length of deafness, 11.5 years) who received a unilateral CI (mean age at CI, 12.9 years). Intervention Unilateral CI. MAIN OUTCOME MEASURES: Standard speech perception testing (Consonant-Nucleus-Consonant [CNC] monosyllabic word test and Hearing in Noise [HINT] sentence test) was performed preoperatively, 1 year postoperatively (year 1), and at the last follow-up/end of the study (EOS). RESULTS: There was a highly significant improvement in speech perception scores for both HINT sentence and CNC word testing from the preoperative testing to year 1 (mean change score, 51.10% and 32.23%, respectively; P < .001) and from the preoperative testing to EOS (mean change score, 60.02% and 38.73%, respectively; P < .001), with a significantly greater increase during the first year (P < .001). In addition, there was a highly significant correlation between improvements in performance scores on the CNC word and HINT sentence speech perception tests and both age at CI and length of deafness at the year 1 testing (P </=.009) but not from the year 1 testing to EOS testing. Adolescents with progressive deafness and those using oral communication before CI performed significantly better than age-matched peers. CONCLUSIONS: Adolescents with prelingual deafness undergoing unilateral CI show significant improvement in objective hearing outcome measures. Patients with shorter lengths of deafness and earlier age at CI tend to outperform their peers. In addition, patients with progressive deafness and those using oral communication have significantly better objective outcomes than their peers

OBJECTIVE: To further define the spectrum of clinical presentation and explore the histologic sequelae of jugular bulb abnormalities (JBAs). DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: Thirty patients with radiologic evidence of inner ear dehiscence by JBA. MAIN OUTCOME MEASURE: Thirty patients with radiologic inner ear dehiscence by JBA and 1579 temporal bone specimens were evaluated for consequences from JBA. RESULTS: We found that JBA-associated inner ear dehiscence could be identified on computed tomography of the temporal bone but not on magnetic resonance imaging scan. Jugular bulb abnormalities eroded the vestibular aqueduct most often (in 25 patients), followed by the facial nerve (5 patients) and the posterior semicircular canal (4 patients). Half of the patients (15) were asymptomatic. Results from vestibular evoked myogenic potential (VEMP) tests were positive in 8 of 12 patients with inner ear dehiscence. Histologically, only 2 of 41 temporal bones with dehiscence of the vestibular aqueduct demonstrated endolymphatic hydrops. CONCLUSIONS: Jugular bulb abnormalities can erode into the vestibular aqueduct, facial nerve, and the posterior semicircular canal. While symptoms may include pulsatile tinnitus, vertigo, or conductive hearing loss, in contrast to earlier reports, half of the patients were asymptomatic. Dehiscence of vestibular aqueduct rarely leads to clinical or histologic hydrops. The VEMP testing was useful in confirming the presence of inner ear dehiscence due to JBAs. Because the natural history of JBAs is unknown, these patients should be followed closely to evaluate for progression of the JBA or development of symptoms

Recent studies highlight the importance of BRAF alterations resulting in mitogen activated protein kinase (MAK/ERK) pathway activation in low-grade CNS tumors. We studied 106 low-grade CNS neoplasms in a cohort of primarily pediatric patients to identify the prevalence and clinicopathologic significance of these alterations. Polymerase chain reaction testing identified KIAA1549:BRAF fusions in 51 (48%) tumors overall, including 42 (60%) pilocytic astrocytomas, 4 (17%) unclassifiable low-grade gliomas, 4 (36%) low-grade glioneuronal/neuroepithelial tumors, 0 (of 5) pleomorphic xanthoastrocytomas, 0 (of 4) diffuse astrocytomas (World Health Organization grade II), and 1 (of 3, 33%) pilomyxoid astrocytoma. KIAA1549:BRAF gene fusions confirmed by sequencing included the previously reported ones involving exons 1-16/9-18 (49%), 1-15/9-18 (35%), and 1-16/11-18 (8%) and 2 fusions with novel breakpoints: 1-15/11-18 (6%) and 1-17/10-18 (1%). DNA sequencing identified BRAF mutations in 8% of tumors. BRAF mutations were absent. KIAA1549:BRAF fusions were significantly more frequent in infratentorial (57%) and optic pathway (59%) tumors versus supratentorial (19%) tumors (p = 0.001). We did not identify significantly improved progression-free survival in tumors with fusions. In summary, KIAA1549:BRAF fusions predominate in pilocytic astrocytomas but are also present in some low-grade unclassifiable gliomas and glioneuronal tumors. The prognostic and therapeutic significance of this alteration is unclear and merits further study.