Faculty Bibliography

The treatment of laryngotracheal stenosis has evolved over the past several decades. Advances in technology, equipment and medication have increased our ability to treat some airway stenosis in a minimally invasive manner, and at times by an endoscopic method. With improved precision, our results with postoperative voice and swallowing should improve

A 50-year-old woman who had undergone cervical spine fixation 6 years earlier presented with dysphagia, regurgitation of undigested food, halitosis, and weight loss. Operative examination demonstrated a hypopharyngeal diverticulum with spinal hardware visible in a defect in the mucosa. She underwent an open cervical approach to removal of the hardware. Endoscopic staple diverticulotomy as described by Scher and Richtsmeier was performed 8 weeks later in the ambulatory surgical setting. After a period of enteral feeding via a nasogastric tube in the initial postoperative period, she was able to resume oral nutrition in the interim between the surgical procedures. After the second procedure, she was able to resume a normal diet immediately and she experienced minimal symptoms. It is established that traction diverticulum is appropriately treated by removing the inciting anatomic factor(s). We propose that staged surgical management begin with the removal of the nidus followed by marsupialization of the diverticulum pouch. Standard staple diverticulotomy is a viable option for the second stage. This technique allows the patient to minimize the length of, or avoid, the second hospitalization for diverticulum management

BACKGROUND: Oral cancer continues to be diagnosed and treated at a late stage, which has a negative effect on outcomes. This study identified and quantified delays in diagnosis and treatment. METHODS: The authors conducted a study that included all new patients seen in the Department of Oral and Maxillofacial Surgery, University of California, San Francisco, between 2003 and 2007 who had a diagnosis of squamous cell carcinoma of the oral cavity. They identified the time intervals for six stages, beginning with the time at which patients first became aware of symptoms and ending with the time at which definitive treatment began. RESULTS: The total time from patients' first sign or symptoms to commencement of treatment was a mean of 205.9 days (range, 52-786 days). The longest delay was from the time symptoms first appeared to the initial visit to a health care professional (mean time, 104.7 days; range, 0-730 days). CONCLUSIONS: Health care professionals need to place greater emphasis on patient education to encourage early self-referrals. CLINICAL IMPLICATIONS: Patients should be encouraged to visit a health care professional when signs or symptoms of oral cancer first develop

We evaluate the effects of adjuvant treatment with the angiogenesis inhibitor Avastin (bevacizumab) on pathological tissue specimens of high-grade glioma. Tissue from five patients before and after treatment with Avastin was subjected to histological evaluation and compared to four control cases of glioma before and after similar treatment protocols not including bevacizumab. Clinical and radiographic data were reviewed. Histological analysis focused on microvessel density and vascular morphology, and expression patterns of vascular endothelial growth factor-A (VEGF-A) and the hematopoietic stem cell, mesenchymal, and cell motility markers CD34, smooth muscle actin, D2-40, and fascin. All patients with a decrease in microvessel density had a radiographic response, whereas no response was seen in the patients with increased microvessel density. Vascular morphology showed apparent 'normalization' after Avastin treatment in two cases, with thin-walled and evenly distributed vessels. VEGF-A expression in tumor cells was increased in two cases and decreased in three and did not correlate with treatment response. There was a trend toward a relative increase of CD34, smooth muscle actin, D2-40, and fascin immunostaining following treatment with Avastin. Specimens from four patients with recurrent malignant gliomas before and after adjuvant treatment (not including bevacizumab) had features dissimilar from our study cases. We conclude that a change in vascular morphology can be observed following antiangiogenic treatment. There seems to be no correlation between VEGF-A expression and clinical parameters. While the phenomena we describe may not be specific to Avastin, they demonstrate the potential of tissue-based analysis for the discovery of clinically relevant treatment response biomarkers

BACKGROUND: Bilateral cleft lip-cleft palate is associated with nasal deformities typified by a short columella. The authors compared nasal outcomes of cleft patients treated with banked fork flaps to those of patients who underwent nasoalveolar molding and primary retrograde nasal reconstruction. METHODS: A retrospective review of 26 consecutive patients with bilateral cleft lip-cleft palate was performed. Group 1 patients (n = 13) had a cleft lip repair and nasal correction with banked fork flaps. Group 2 patients (n = 13) had nonsurgical columellar elongation with nasoalveolar molding followed by cleft lip closure and primary retrograde nasal correction. Group 3 patients (n = 13) were age-matched controls. Columellar length was measured at presentation and at 3 years of age. The number of nasal operations was recorded to 9 years. The Kruskal-Wallis and Tukey-Kramer tests were used for statistical analysis. RESULTS: Initial columellar length was 0.49 +/- 0.37 mm in group 1 and 0.42 +/- 0.62 mm in group 2. Post-nasoalveolar molding columellar length was 4.5 +/- 0.76 mm in group 2. By 3 years of age, columellar length was 3.03 +/- 1.47 mm in group 1, 5.98 +/- 1.09 mm in group 2, and 6.35 +/- 0.99 mm in group 3. Group 2 columellar length was significantly greater (p < 0.001) than that of group 1 and not statistically different from that of group 3 (p > 0.05). All group 1 patients (13 of 13) needed secondary nasal surgery. No nasoalveolar molding patients (zero of 13, group 2) required secondary nasal surgery. CONCLUSION: Nonsurgical columellar elongation with nasoalveolar molding followed by primary retrograde nasal reconstruction restored columellar length to normal by 3 years and significantly reduced the need for secondary nasal surgery.

OBJECTIVE: To describe a safe and effective technique for the implantation of common cavity cochleae. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Fifteen cochleae in 9 adults and children with common cavity deformities implanted with and without the use of intraoperative fluoroscopy. INTERVENTION(S):: Fluoroscopically assisted cochlear implantation. MAIN OUTCOME MEASURE(S): Rates of extracochlear placement, bending, kinking, intrameatal placement, and complications were analyzed. Numbers of electrodes inserted, number of active electrodes, and speech performance were compared between the 2 groups. RESULTS: Half of the nonfluoroscopy group had suboptimal placement of their electrode arrays. This group also had a higher rate of complications, lower numbers of electrodes implanted, and lower number of active electrodes at follow-up. Results of speech perception testing suggest that fluoroscopically assisted implantation of the common cavity results in improved performance. CONCLUSION: Intraoperative fluoroscopy is an easy, safe, and effective technique that results in improved outcomes for cochlear implant patients with common cavity deformities