Faculty Bibliography

OBJECTIVES: To provide comprehensive temporal trend analysis of 5-year relative survival rates of laryngeal cancer using the Surveillance, Epidemiology, and End Results database; and to expand on prior reports by including inclusion of laryngeal tumor location, stage, age at diagnosis, treatment strategy, and histologic grade. DESIGN: Retrospective cohort analysis using the Surveillance, Epidemiology, and End Results database of the National Cancer Institute. The Surveillance, Epidemiology, and End Results data were used to design 5 cohorts of patients with laryngeal cancer: 1977-1978, 1983-1984, 1989-1990, 1995-1996, and 2001-2002. Five-year survival rates were analyzed according to tumor site, stage, and grade; age at diagnosis; and treatment strategy. The joinpoint regression model was used to assess survival trends and their statistical significance. RESULTS: Among patients with supraglottic cancer, 5-year relative survival rates for distant disease worsened over time while rates for local and regional disease did not change (P = .01 and P > .05, respectively). For localized glottic cancer, survival remained stable from 1977-1978 to 2001-2002. However, patients with regional and distant glottic cancer demonstrated a significant decrease in survival in the past 3 decades (P < .001). This trend was independent of treatment strategy. Finally, the proportion of well-differentiated tumors in patients with regional laryngeal cancer decreased over time (P < .001 for supraglottic and P = .007 for glottic). CONCLUSIONS: A decreasing 5-year survival trend was found among patients with glottic cancer who had regional disease and in all patients with distant disease. Histopathologic trends not previously reported in those with laryngeal cancer seem to parallel those seen in other tobacco-related cancers. These trends may reflect the effect of birth cohorts and implicate the relationship between carcinogenic exposure and host factors, rather than the influence of treatment

BACKGROUND: The efficacy of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) for treatment of nasal polyposis was demonstrated in 2 large clinical trials. OBJECTIVE: To evaluate the onset of MFNS symptomatic effect, data from the 2 trials were pooled and analyzed to determine the first day subjects experienced significant symptom relief. METHODS: Subjects with nasal polyposis randomized to MFNS 200 microg twice daily or placebo scored symptoms on a 3-point scale (0 = none; 3 = severe) and measured peak nasal inspiratory flow immediately before the morning dose. Onset of symptomatic effect was defined as the first day a statistically significant (P < .05) lasting response was observed for MFNS compared with placebo. RESULTS: A total of 447 subjects with bilateral nasal polyps and clinically significant nasal congestion/obstruction were analyzed. Compared with placebo, MFNS 200 microg twice daily demonstrated statistically significant (P < .05) relief of anterior rhinorrhea by day 2 (-10.9% vs +5.7%), nasal congestion by day 3 (-15.1% vs -7.6%), postnasal drip by day 5 (+1.1% vs +4.6%), and sense of smell by day 13 (-9.6% vs -5.6%). Significant improvement in peak nasal inspiratory flow was seen by day 2 (increase of 6.22 L/min vs 1.48 L/min for placebo; P = .03). CONCLUSION: Mometasone furoate nasal spray 200 microg twice daily rapidly improves the symptoms of nasal polyposis, leading to lasting relief of most major symptoms within 2 (24 hours after the first dose) to 5 days of initiating therapy.

BACKGROUND: The incidence of thyroid cancer in black Americans is half that in white Americans. It is unknown whether this gap represents a population difference in disease or is attributable to inferior cancer screening in the black population. METHODS: A population-based cohort study of 53,990 patients (1973-2003) was performed using the National Cancer Institute's Surveillance Epidemiology End Results database. Socioeconomic variables were explored using the Healthcare Cost and Utilization Project database and macroeconomic data. RESULTS: Since 1973, thyroid cancer incidence among whites has increased 150.2% (4.0 to 9.9 of 100,000), while incidence among blacks has increased 73.2% (3.0 to 5.1 of 100,000). Across 17 regions, the incidence correlated with the percentage of the population with health insurance (r = 0.56, P = .02). Regression analysis suggested that half of the black-white incidence gap might be attributable to differences in health insurance status. Patients with thyroid cancer were more likely to be insured or reside in wealthier ZIP codes. Black patients were more likely to present at advanced age (RR 1.08, P < .0001) and with tumors >4 cm in size (RR 1.13, P <.0001). Black patients were slightly less likely to present with advanced disease (RR 0.96, P = .0008). Cancer-specific mortality was identical in the two populations. DISCUSSION: Sociodemographic data and differences at presentation support a small detection disparity in thyroid cancer, which may contribute to part of the incidence gap. However, this effect is not sufficiently strong to fully explain the incidence gap. A population difference in the incidence of disease may be coexistent

Tumors of the cerebellopontine angle (CPA) are common and represent up to 10% of all intracranial tumors. Rarely, intrinsic brainstem tumors can involve the CPA and present with auditory symptoms typical of CPA tumors such as hearing loss, vertigo and tinnitus. We report on a rare case of an intrinsic brainstem neoplasm presenting with steroid responsive fluctuating sensorineural hearing loss in a child. The patient initially presented with an acute worsening of an unilateral sensorineural hearing loss, without additional symptoms, that responded to oral steroids. Otoacoustic emission testing demonstrated normal outer hair cell function suggesting retrocochlear pathology. Magnetic resonance imaging with contrast enhancement revealed an intrinsic neoplasm of the middle cerebellar peduncle impinging on the 7th/8th neurovascular bundle within the CPA. The patient underwent gross total resection of the juvenile pilocytic astrocytoma via retrosigmoid craniotomy and remains disease free at 2 years postoperatively. This case highlights that suspicion of central nervous system pathology should be heightened in the presence of steroid responsive, fluctuating sensorineural hearing loss with normal outer hair cell function

Objective: To examine speech perception outcomes and determine the impact of length of deafness and time between implants on performance in the sequentially bilateral implanted population. STUDY DESIGN: Retrospective review. SETTING: Tertiary academic referral center. PATIENTS: Forty-three children (age, <18 yr) and 22 adults underwent sequential bilateral implantation with at least 6 months between surgeries. The mean age at the time of the second implant in children was 7.83 years, and mean time between implants was 5.16 years. Five children received the first side implant (C1) below 12 months of age; 16, at 12 to 23 months; 9, between the ages of 24 and 35 months; and 11, at 36 to 59 months; 2 were implanted above the age of 5 years. In adults, mean age at second implant was 46.6 years, and mean time between implants was 5.6 years. INTERVENTION: Sequential implantation with 6 months or more between implantations. MAIN OUTCOME MEASURES: Speech perception tests were performed preoperatively before the second implantation and at 3 months postoperatively. RESULTS: Results revealed significant improvement in the second implanted ear and in the bilateral condition, despite time between implantations or length of deafness; however, age of first-side implantation was a contributing factor to second ear outcome in the pediatric population. CONCLUSION: Sequential bilateral implantation leads to significantly better speech understanding. On average, patients improved, despite length of deafness, time between implants, or age at implantation

Spike timing-dependent synaptic plasticity (STDP) plays an important role in neural development and information processing in the brain; however, the mechanism by which spike timing information is encoded into STDP remains unclear. Here, we show that a novel allosteric kinetics of NMDA receptors (NMDARs) is required for STDP. We developed a detailed biophysical model of STDP and found that the model required spike timing-dependent distinct suppression of NMDARs by Ca(2+)-calmodulin. This led us to predict an allosteric kinetics of NMDARs: a slow and rapid suppression of NMDARs by Ca(2+)-calmodulin with prespiking --> postspiking and postspiking --> prespiking, respectively. We found that the allosteric kinetics, but not the conventional kinetics, is consistent with specific features of amplitudes and peak time of NMDAR-mediated EPSPs in experiments. We found that the allosteric kinetics of NMDARs was also valid for synaptic plasticity induced by more complex spike trains in layer II/III of visual cortex. We extracted an essential synaptic learning rule by reduction of the allosteric STDP model and found that spike timing-dependent bidirectional role of postspiking in synaptic modification, which depends on the allosteric kinetics, is the essential principle in STDP. Thus, we propose a simple hypothesis of the allosteric kinetics of NMDARs that can coherently explain critical features of spike timing-dependent NMDAR-mediated EPSPs and synaptic plasticity

We investigated the cannabinoid receptor (CBr) agonists Win55,212-2 (non-selective) and AM1241 (CBr2 selective) and the peripheral receptor (CBr1) in carcinoma-induced pain using a mouse model. Tumors were induced in the hind paw of female mice by local injection of a human oral squamous cell carcinoma (SCC). Significant pain, as indicated by reduction in withdrawal thresholds in response to mechanical stimulation, began at 4 days after SCC inoculation and lasted to 18 days. Local administration of Win55,212-2 (10 mg/kg) and AM1241 (10 mg/kg) significantly elevated withdrawal thresholds, indicating an antinociceptive effect. Ipsilateral expression of CBr1 protein in L5 DRG was significantly upregulated compared to ipsilateral L4 DRG and in normal tissue. These findings support the suggestion that cannabinoids are capable of producing antinociception in carcinoma-induced pain

OBJECTIVE: To characterize the background and outcomes of tonsillectomy malpractice claims. METHODS: Review of 69 New York State insurance claims (Part I) and 87 national court trials (Part II) alleging injury after tonsillectomy. RESULTS: Part I. New York State insurance cases were most commonly discontinued (44%) or settled (42%) before trial. Compensations with a settlement or verdict were made in 48 percent of cases. Part II. Death or major injury occurred in 52 percent of insurance cases, with a mean award of $403,656 being made to plaintiffs. Of cases reaching trial, 60 percent of plaintiffs were compensated. Awards against anesthesiologists were more frequent and higher than against surgeons ($5 million vs $839,650). Death or major injury occurred in 52 percent of court cases, resulting in mean indemnity of $3.8 million. Most cases of death or major injury were attributable to airway complications. CONCLUSIONS: Approximately half of both New York state claims and court cases involved death or devastating morbidity, mostly related to airway complications, resulting in large awards. Tonsillectomy is a source of uncommon but potentially high-dollar-value litigation exposure to the surgeon, often attributable to non-surgical complications

OBJECTIVE: To determine the rate of hematoma formation in drainless deep-plane rhytidectomy and compare it with the rate using the same technique with the use of fibrin glue. METHODS: This is a retrospective review of 605 patients (78 male and 527 female) who, over a 6-year period, underwent deep-plane face-lift surgery (n = 544) or lateral superficial musculoaponeurotic system (SMAS)ectomy (n = 61) by the senior author (S.S.R.) without the use of surgical drains. One hundred forty-six consecutive patients underwent rhytidectomy without fibrin tissue glue, and the following 459 consecutive patients were sprayed with fibrin glue under the flap prior to flap closure. Pressure dressings were used on all patients for 24 hours. RESULTS: None of the patients in either group had major or expanding hematomas requiring operative intervention. In the group of patients treated without fibrin glue (n = 146), there were 5 minor, nonexpanding hematomas, all managed by needle aspiration. This is a minor hematoma rate of 3.4%. In the fibrin glue group (n = 459), there were 2 hematomas, for a rate of 0.4%. Using a Fisher exact test, we found a statistically significant decrease in the hematoma rate from 3.4% to 0.4% (P = .01). Male patients had a higher hematoma rate than female patients, and only men had significantly fewer hematomas when fibrin glue was applied (P = .01). All 7 hematomas were recognized in the first 24 hours after surgery. Of the 7 patients with hematomas, 2 (29%) had emesis in the recovery room despite medication. CONCLUSIONS: The use of fibrin glue demonstrates a significant decrease in the rate of hematoma formation. Fibrin glue may benefit male more than female patients. If meticulous hemostasis and pressure dressings are used, drains are not necessary. The prevention and prompt treatment of postoperative nausea may also help prevent hematoma formation