Faculty Bibliography

BACKGROUND: Radiation is a known risk factor for poor wound healing. Patients undergoing intraoperative radiation therapy (IORT) typically receive higher cumulative doses to their wound beds than patients treated with conventional radiation therapy. We review our experience with IORT in patients undergoing resection of head and neck cancer and flap reconstruction. Logistics of delivery and outcomes are discussed. METHODS: A retrospective chart review was performed on all patients at Beth Israel Medical Center who underwent IORT for head and neck cancer between 2000 and 2007. Twenty-one patients receiving 22 treatments involving flap reconstruction were identified. The results of these reconstructions were evaluated for complications and functional outcome. RESULTS: All patients had complex surgical wounds of the face, upper aerodigestive tract, or neck who received IORT in conjunction with pedicled or free flap closure. Twenty-five flaps in 21 patients were performed in the setting of IORT. All patients received between 10 and 15 Gy of IORT administered directly to the wound bed. There were no perioperative mortalities. Wound breakdown occurred in three cases, all of which were treated successfully by operative revision. Functionally, most patients did well and performed similarly to historic controls for their type of reconstruction. CONCLUSIONS: Reconstruction using flaps in the context of IORT can be achieved with expectation of good wound healing in the majority of cases despite heavy cumulative doses of radiation to recipient wound beds.

OBJECTIVE: Demonstrate the benefits of a multidisciplinary pediatric airway team prepared to evaluate and treat otolaryngology patients with flexible bronchoscopy. DESIGN: Case series. SETTING: Tertiary, academic children's hospital. PATIENTS: 10 children (5 male, 5 female age range 2 months-16 years) presenting with complex symptoms potentially referable to large airways. INTERVENTION: Flexible bronchoscopy for diagnostic (bronchoalveolar lavage, ciliary biopsy, assess ongoing surgical intervention, and rule in or rule out foreign body; N=6) or therapeutic (evacuate bronchial mucus plug, laser subglottis when patient has fused cervical spine, and distal instillation [fibrin glue for bronchopleural fistula and dornase alpha for plastic bronchitis]; N=4). MAIN OUTCOME MEASURE: Retrospectively ask if flexible bronchoscopy and interdisciplinary management improved patient care in these select otolaryngology cases. RESULTS: 10/10 patients benefited from interdisciplinary management including flexible bronchoscopy. CONCLUSION: Our experience illustrates many uses for flexible bronchoscopy in otolaryngology patients, and suggests that an airway team prepared to use flexible bronchoscopy will create opportunities for improved patient care.

Neural activity in the frontal eye fields controls smooth pursuit eye movements, but the relationship between single neuron responses, cortical population responses, and eye movements is not well understood. We describe an approach to dynamically link trial-to-trial fluctuations in neural responses to parallel variations in pursuit and demonstrate that individual neurons predict eye velocity fluctuations at particular moments during the course of behavior, while the population of neurons collectively tiles the entire duration of the movement. The analysis also reveals the strength of correlations in the eye movement predictions derived from pairs of simultaneously recorded neurons and suggests a simple model of cortical processing. These findings constrain the primate cortical code for movement, suggesting that either a few neurons are sufficient to drive pursuit at any given time or that many neurons operate collectively at each moment with remarkably little variation added to motor command signals downstream from the cortex.

BACKGROUND: Plate osteosynthesis is a widely used technique in head and neck reconstructive surgery. The objective of this study was to determine whether postoperative chemoradiotherapy, which was recently introduced for high-risk head and neck cancer, affects plate and osteosynthesis related complications. METHODS: Fifty-two consecutive patients, who had undergone plate osteosynthesis for mandibular reconstruction between October 2003 and September 2006, were included in the study. The patients were divided into 3 groups: (1) surgery alone (n = 19), (2) surgery with postoperative radiotherapy (n = 14), and (3) surgery with concurrent chemoradiotherapy (n = 19). Outcome measures included any bone or plate related complications. RESULTS: The plate and osteosynthesis related complications occurred in 10.5% of patients in surgery-alone group, 28.6% in surgery with postoperative radiation group, and 63.2% in surgery with postoperative concurrent chemoradiotherapy group. The differences in the complication rates among these 3 groups were statistically significant (p = .003). In univariate analysis, postoperative radiation (p = .007) and concurrent chemotherapy (p = .003) were found to be significantly associated with complications. In multivariate analysis, only concurrent chemotherapy was found to be statistically significant (p = .002) with odds ratio of 7.72. CONCLUSION: Postoperative concurrent chemoradiotherapy significantly increases plate and osteosynthesis related complications in oral cancer.

OBJECTIVE: To compare quality of life (QOL) of patients with advanced laryngeal cancers treated by total laryngectomy with those who received concurrent chemoradiotherapy. STUDY DESIGN: This is a cross-sectional study of the patients treated in our institution who have completed one year of follow-up and were disease-free at the time of evaluation. SUBJECTS AND METHOD: Forty patients treated for advanced cancer of the larynx (stage III/IV), either by concurrent chemoradiation (11) or total laryngectomy and postoperative radiation (29), have been included in this study. The Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) version 4 questionnaire was used. RESULTS: Total scores for overall QOL are equal in both treatment groups (P = 0.69). Scores for individual components are similar in both treatment groups. However, dryness of mouth is significantly worse in the chemoradiotherapy group (P = 0.01) and ability to communicate with others is poorer in the laryngectomy group (P = 0.03). CONCLUSION: Long-term overall QOL remains similar in all the patients treated for advanced carcinoma of the larynx irrespective of treatment modality.

BACKGROUND: Stomal stenosis after laryngectomy is a common and distressing complication. Once sets in, it is generally progressive, causes problems and needs active intervention. AIM: To evaluate effectiveness of new simple method of stomaplasty in solving troublesome complication of stoma stenosis. SETTINGS AND DESIGN: Charts of eight patients who underwent modified stomaplasty and completed 1 year were reviewed. MATERIALS AND METHODS: A modified anterior advancement flap and lateral splaying of trachea for stoma plasty are described. This involves excision of scar tissue of the anterior two-third of trachea and interposition of the defect with an inferiorly based triangular skin flap. The tracheo-esophageal-prosthesis (TEP) site is left untouched. STATISTICAL ANALYSIS: Outcome were measured in relation with need for further stenting or any other revision procedure required and ability to use TEP for speech production. RESULTS: Eight patients underwent stoma revision surgery. Median preprocedure stoma diameter was 10 mm vertically (range 8-12 mm) and 6 mm horizontally (range 5-10 mm). This could be improved to 25 mm (range 22-30 mm) vertically and 16 mm (range 14-20 mm) horizontally after stoma revision. At 1-year follow-up, the median measurements were 20 mm (range 16-26) vertically and 14 mm (range 12-18) horizontally. Postprocedure, one patient required intermittent stenting at nighttime. All patients could use the TEP effectively. One patient who underwent salvage laryngectomy following chemoradiotherapy developed flap dehiscence. CONCLUSIONS: This is a simple and effective technique for stomaplasty. All patients treated with this technique had adequately large stoma for breathing and use of TEP.

Amplitude modulations of pulsitile stimulation can be used to convey pitch information to cochlear implant users. One variable in designing cochlear implant speech processors is the choice of modulation waveform used to convey pitch information. Modulation frequency discrimination thresholds were measured for 100 Hz modulations with four waveforms (sine, sawtooth, a sharpened sawtooth, and square). Just-noticeable differences (JNDs) were similar for all but the square waveform, which often produced larger JNDs. The results suggest that a sine, sawtooth, and sharpened sawtooth waveforms are likely to provide similar pitch discrimination within a speech processing strategy.