Faculty Bibliography

BACKGROUND:Long-term survival of heart transplants is hampered by chronic rejection (CR). Studies indicate the involvement of host macrophages in the development of CR; however, the precise role of these cells in CR is unclear. Thus, it is important to develop noninvasive techniques to serially monitor the movement and distribution of recipient macrophages in chronic cardiac allograft rejection in vivo. METHODS AND RESULTS/RESULTS:We have employed a rat heterotopic working-heart CR model for a magnetic resonance imaging experiment. Twenty-one allograft (PVG.1U-->PVG.R8) and 9 isograft (PVG.R8-->PVG.R8) transplantations were performed. Recipient macrophages are labeled via intravenous injection of micron-sized paramagnetic iron oxide particles (0.9 microm in diameter) at a dose of 4.5 mg Fe per rat 1 day before transplantation. Serial in vivo magnetic resonance images were acquired for up to 16 weeks. The migration of labeled recipient cells in our CR model, in which cardiac CR is evident at 3 weeks and most extensive by 16 weeks after transplantation, can be assessed with the use of in vivo magnetic resonance imaging for >100 days after a single micron-sized paramagnetic iron oxide injection. The location and distribution of labeled recipient cells were confirmed with magnetic resonance microscopy and histology. CONCLUSIONS:This approach may improve our understanding of the immune cells involved in CR and the management of heart transplantation. Moreover, this study demonstrates the feasibility of noninvasively observing individual targeted cells over long time periods by serial in vivo magnetic resonance imaging.

BACKGROUND:Intraoperative surgical navigation has become widely accepted as an important tool for improvement of surgical outcomes and reduction of complication in endoscopic sinus surgery (ESS). The purpose of this study was to assess the clinical utility of intraoperative volume computed tomography (CT) scanning in endoscopic sinonasal and skull base procedures. METHODS:Retrospective review of patients who underwent intraoperative volume CT imaging (xCAT; XoranTechnologies, Ann Arbor, MI) during endoscopic sinonasal and skull base surgery during a 3-month period was performed. Intraoperative, computer-enabled triplanar review of reformatted 0.4-mm images was performed in all cases. RESULTS:Intraoperative volume CT scanning was completed in 25 patients. Surgical procedures included revision/primary ESS for chronic rhinosinusitis (CRS) with or without polyposis (12 cases) and mucoceles (6 cases) as well as endoscopic neoplasm resection (5 cases), endoscopic fibro-osseous lesion resection (1 case), and endoscopic meningoencephalocele repair (1 case). The indications for intraoperative CT scanning included assessment of surgical dissection (23 cases), extent of tumor resection (6 cases), and frontal stent placement (6 cases). Based on the intraoperative volume CT information, additional interventions, including additional tumor resection (2 cases), dissection of ethmoid partitions (2 cases), frontal bone drilling during Draf IIB (1 case), and repositioning of a frontal stent (1 case) were performed in 6 (24%) cases. CONCLUSION/CONCLUSIONS:Intraoperative volume CT scanning was successfully performed in 25 patients undergoing ESS. Because additional surgical intervention was performed in 24% of cases, this technology may have an important role in endoscopic sinonasal and skull base procedures.

BACKGROUND:Treatment of patients with failed frontal sinus (FS) obliteration (FSO) remains an important challenge in the endoscopic era. Advances in endoscopic techniques have facilitated the application of minimally invasive approaches for clinical scenarios that previously required open procedures. METHODS:A retrospective chart review of patients presenting with failed FSO from January 1, 2001 to June 30, 2007 was performed. RESULTS:Seventeen patients (mean age, 52.8 years; 10 men and 7 women) presented at an average of 9.7 years from initial FSO. The most common primary presenting symptoms included headache (41.2%) and forehead swelling (23.5%). Seven patients had prior craniotomies and 10 patients had prior endoscopic sinus surgery. All patients underwent surgical exploration; revision procedures were required in 5 patients. Definitive procedures included endoscopic frontal sinusotomy (EFS; 10 patients), endoscopic frontal drill-out (3 patients), revision osteoplastic frontal sinusotomy with obliteration reversal (2 patients), and repeat FSO (2 patients). One patient required revision EFS twice. Initial intraoperative findings included mucocele (13 cases), bone wax (3 cases), fibrous tissue (2 cases), and polypoid mucosa (1 case). All patients had resolution or improvement of their primary presenting signs/symptoms. All FSO reversal patients achieved functional FS patency documented by endoscopy and/or CT scan with mean follow-up of 9.5 months (range, 1.5-30.8 months). CONCLUSION/CONCLUSIONS:Operative exploration should be considered in all patients with persistent or recurrent symptoms and/or signs of failed FSO. In most instances, repeat FSO can be avoided, and a minimally invasive endoscopic strategy can be used successfully.

BACKGROUND:Nebulized budesonide (Pulmicort Respules, AstraZeneca, Wilmington, DE) provides control of respiratory tract inflammation in asthmatic patients. The Mucosal Atomization Device (MAD; Wolfe-Tory Medical, Salt Lake City, UT) is a novel sinonasal atomization device. METHODS:Uncontrolled case series of postoperative patients with chronic rhinosinusitis (CRS) who received budesonide via MAD was performed. RESULTS:A total of 44 patients with a mean age of 53.5 years met inclusion criteria. The average follow-up was 31.5 weeks (SD 17.55; range, 8 to 80 weeks). Overall, patient and physician global assessments demonstrated moderate to significant improvement. Average daily oral prednisone usage among patients who took systemic steroids (n = 27) was reduced from 7.96 to 1.94 mg/day without relapse of polyps, mucosal edema, and nasal discharge. Prednisone use was reduced to zero in 16 patients and reduced or stabilized in 10 other patients. CONCLUSION/CONCLUSIONS:Topical budesonide via MAD may reduce the need for systemic prednisone and improve both physician and patient global assessment scores in postoperative CRS patients. Additional investigation is warranted to exclude placebo effect, spontaneous resolution, and regression to the mean as responsible factors for the reported findings.

PURPOSE OF REVIEW/OBJECTIVE:Pressure is mounting on physicians to adopt electronic medical records. The field of health information technology is evolving rapidly with innovations and policies often outpacing science. We sought to review research and discussions about electronic medical records from the past year to keep abreast of these changes. RECENT FINDINGS/RESULTS:Original scientific research, especially from otolaryngologists, is lacking in this field. Adoption rates are slowly increasing, but more of the burden is shouldered by physicians despite policy efforts and the clear benefits to third-party payers. Scientific research from the past year suggests lack of improvements and even decreasing quality of healthcare with electronic medical record adoption in the ambulatory care setting. The increasing prevalence and standardization of electronic medical record systems results in a new set of problems including rising costs, audits, difficulties in transition and public concerns about security of information. SUMMARY/CONCLUSIONS:As major players in healthcare continue to push for adoption, increased effort must be made to demonstrate actual improvements in patient care in the ambulatory care setting. More scientific studies are needed to demonstrate what features of electronic medical records actually improve patient care. Otolaryngologists should help each other by disseminating research about improvement in patient outcomes with their systems since current adoption and outcomes policies do not apply to specialists.

The MHC-encoded cofactor DM catalyzes endosomal loading of peptides onto MHC class II molecules. Despite evidence from in vitro experiments that DM acts to selectively edit the repertoire of class II:peptide complexes, the consequence of DM expression in vivo, or a predictive pattern of DM activity in the specificity of CD4 T cell responses has remained unresolved. Therefore, to characterize DM function in vivo we used wild-type (WT) or DM-deficient (DM(-/-)) mice of the H-2(d) MHC haplotype and tested the hypothesis that DM promotes narrowing of the repertoire of class II:peptide complexes displayed by APC, leading to a correspondingly selective CD4 T cell response. Surprisingly, our results indicated that DM(-/-) mice do not exhibit a broadened CD4 T cell response relative to WT mice, but rather shift their immunodominance pattern to new peptides, a pattern associated with a change in class II isotype-restriction. Specifically, we found that CD4 T cell responses in WT mice were primarily restricted to the I-A class II molecule, whereas DM(-/-) mice recognize peptides in the context of I-E. The observed shift in isotype-restriction appeared to be due in part to a modification in the peripheral CD4 T cell repertoire available for peptide recognition.

Neuroimaging studies of speech processing increasingly rely on artificial speech-like sounds whose perceptual status as speech or non-speech is assigned by simple subjective judgments; brain activation patterns are interpreted according to these status assignments. The naive perceptual status of one such stimulus, spectrally-rotated speech (not consciously perceived as speech by naive subjects), was evaluated in discrimination and forced identification experiments. Discrimination of variation in spectrally-rotated syllables in one group of naive subjects was strongly related to the pattern of similarities in phonological identification of the same stimuli provided by a second, independent group of naive subjects, suggesting either that (1) naive rotated syllable perception involves phonetic-like processing, or (2) that perception is solely based on physical acoustic similarity, and similar sounds are provided with similar phonetic identities. Analysis of acoustic (Euclidean distances of center frequency values of formants) and phonetic similarities in the perception of the vowel portions of the rotated syllables revealed that discrimination was significantly and independently influenced by both acoustic and phonological information. We conclude that simple subjective assessments of artificial speech-like sounds can be misleading, as perception of such sounds may initially and unconsciously utilize speech-like, phonological processing.

An important topic in the evolution of language is the kinds of grammars that can be computed by humans and other animals. Fitch and Hauser (F&H; 2004) approached this question by assessing the ability of different species to learn 2 grammars, (AB)(n) and A(n) B(n) . A(n) B(n) was taken to indicate a phrase structure grammar, eliciting a center-embedded pattern. (AB)(n) indicates a grammar whose strings entail only local relations between the categories of constituents. F&H's data suggest that humans, but not tamarin monkeys, learn an A(n) B(n) grammar, whereas both learn a simpler (AB)(n) grammar (Fitch & Hauser, 2004). In their experiments, the A constituents were syllables pronounced by a female voice, whereas the B constituents were syllables pronounced by a male voice. This study proposes that what characterizes the A(n) B(n) exemplars is the distributional regularities of the syllables pronounced by either a male or a female rather than the underlying, more abstract patterns. This article replicates F&H's data and reports new controls using either categories similar to those in F&H or less salient ones. This article shows that distributional regularities explain the data better than grammar learning. Indeed, when familiarized with A(n) B(n) exemplars, participants failed to discriminate A(3) B(2) and A(2) B(3) from A(n) B(n) items, missing the crucial feature that the number of As must equal the number of Bs. Therefore, contrary to F&H, this study concludes that no syntactic rules implementing embedded nonadjacent dependencies were learned in these experiments. The difference between human linguistic abilities and the putative precursors in monkeys deserves further exploration.

BACKGROUND: We reviewed management of the cervical lymph nodes in patients with Merkel cell carcinoma (MCC) of the head and neck. METHODS: Records of 15 patients with MCC of the head and neck area were evaluated for the type of surgical treatment, including wide local excision, sentinel lymph node (SLN) biopsy, neck dissection, postoperative radiation therapy, and clinical outcomes. RESULTS: Median follow-up was 24 months (range, 5-84 months). Ten patients were treated with wide local excision plus SLN, with or without neck dissection. Five patients were treated with wide local excision only or wide local excision plus neck dissection. One patient died of distant metastases (7%), and 14 patients remain alive (93%), over a mean follow-up of 24 months. CONCLUSION: Wide excision and SLN biopsy for primary MCC with N0 neck is feasible for early-stage, previously untreated lesions. SLN biopsy was helpful in determining the nodal levels to be dissected or irradiated.