Faculty Bibliography

INTRODUCTION: Tracheotomy for long-term ventilation is a common surgical procedure in the hospital setting. Although the postoperative care is often perceived as routine, complications associated with tracheostomy changes may result in loss of airway and death. In addition, the practice patterns, rationale, and complications related to tube changes have been poorly described. STUDY DESIGN AND METHODS: A survey of chief residents in accredited otolaryngology training programs was performed to determine the management strategies, rationale, and complications associated with postoperative tracheostomy tube changes. RESULTS: The first tube change was performed after a mean of 5.3 (range, 3-7) days after the procedure, most frequently by junior residents. The first change was performed in a variety of locations including the intensive care unit (88%), step down unit (80%), and regular floor (78%). Twenty-five percent performed these changes at night or on weekends. The most frequently reported rationale for performing routine tracheotomy changes was examination of the stoma for maturity (46%), prevention of stomal infection (46%), and confirmation of stability for transport to a less monitored setting (41%). Twenty-five (42%) respondents reported awareness of a loss of airway, and nine (15%) respondents reported awareness of a death as a result of the first tube change at their institution during their residency. A statistically significant higher incidence of airway loss was reported by respondents who reported performing the first tube change on the floor (96.1% vs. 63.6%). CONCLUSION: There is significant variability in the approach to postoperative tracheostomy tube management. The occurrence of major complications including deaths from routine tube changes requires an examination of the rationale and safety of this practice

Chemodenervation with botulinum toxin has become an integral part of the facial plastic armamentarium. Although eyebrow and eyelid cosmetic deformities and asymmetries have traditionally been treated by surgical intervention, Botox can now be incorporated effectively into the surgical plan. When the surgeon has a complete understanding of facial anatomy and muscular interactions, Botox can be used as a primary treatment of the periorbital region or as an adjunct to surgical procedures of the periorbital region.

PURPOSE: The workup for oral malignancy involving the mandible typically involves a head and neck exam, laboratory studies, a panoramic radiograph, and computed tomography (CT) or magnetic resonance imaging of the head and neck to evaluate the primary lesion and cervical lymph nodes. Panoramic plain film radiography of the mandible is often unreliable for detecting bony invasion; therefore, other imaging studies are necessary before staging is complete. Bony invasion is typically imaged with the use of conventional CT scanners. In this article we relate the use of cone beam computed tomography (CBCT) to image the mandible with less cost and morbidity to the patient and its use in the evaluation and treatment planning of mandibular cancer. MATERIALS AND METHODS: A retrospective review of 3 patients with mandibular malignancies was performed. All patients had a panoramic radiograph, magnetic resonance imaging, and chest radiograph, in addition to laboratory studies. CBCT scans were ordered, after bony involvement was suspected, and compared with the other imaging studies. RESULTS: Two patients with squamous cell carcinoma of anterior mandible and 1 patient with osteogenic sarcoma were reviewed. In all cases CBCT aided the evaluation of the mandible. The cone beam panoramic view, as part of the CBCT, was used to determine extent of resection. CONCLUSION: CBCT can accurately aid in evaluating and treatment planning for malignant tumors of the mandible with less cost and decreased radiation to the patient relative to conventional CT

PURPOSE: The treatment of locally aggressive lesions of the mandible can have a profound effect on a patient's quality of life (QOL), both functionally and psychologically. The more knowledge available on this subject, the better a patient can be prepared and counseled. PATIENTS AND METHODS: Patients undergoing mandibular resection with immediate insertion of a reconstruction plate and subsequent staged reconstruction for the management of locally aggressive lesions of the mandible at the University of California at San Francisco were studied over a 6-year period from 1999 to 2005. The staged reconstruction involved bone grafting, removal of the reconstruction plate, vestibuloplasty, implant insertion, and construction of an implant-supported prosthesis. Each patient completed a modified University of Washington Quality of Life version 4 questionnaire after reaching his or her highest level of reconstruction. RESULTS: A total of 26 patients were identified as fulfilling the criteria for this study. Eight patients did not progress beyond resection, bone grafting, and subsequent removal of the bone plate. Seven patients progressed all the way through the 7 stages to an implant-supported prosthesis. The most important determinants of the patient's subsequent QOL were time interval from initial resection and stage of reconstruction; the greater the time interval from initial resection and the further the stage of reconstruction reached, the better the QOL. Resections involving the mandibular angle had a negative effect on appearance, and resections involving the parasymphysis and symphysis region carried a worse overall QOL, possibly due to difficulty with chewing and lip support. Males reached a higher overall QOL than females. Although most patients seemed satisfied with their overall QOL, 73% had some concerns regarding appearance, 42% had concerns with chewing, 42% had concerns regarding their mood, 35% felt more anxious since the surgery, 23% had some residual pain and discomfort, 19% had concerns with swallowing, and 15% had concerns with taste. CONCLUSION: These and other findings necessitate further investigation and confirmation

OBJECTIVE: To identify, summarize, and evaluate patient-reported outcome questionnaires for use in head and neck cancer surgery with the view to making recommendations for future research. DATA SOURCES: A systematic review of the English-language literature, with the use of head-and-neck-surgery-specific keywords, was performed in the following databases: Medline, Embase, HAPI, CINAHL, Science/Social Sciences Citation Index, and PsycINFO from 1966 to March 2006. DATA EXTRACTION AND STUDY SELECTION: All English-language instruments identified as patient-reported outcome questionnaires that measure quality of life and/or satisfaction that had undergone development and validation in a head and neck cancer surgery population were included. DATA SYNTHESIS: Twelve patient-reported outcome questionnaires fulfilled our inclusion criteria. Of these, four were developed from expert opinion alone or did not have a published development process and seven questionnaires lacked formal item reduction. Only three questionnaires (EORTC Head and Neck Module, University of Michigan Head and Neck Quality-of-life Questionnaire, and Head and Neck Cancer Inventory) fulfilled guidelines for instrument development and evaluation as outlined by the Medical Outcomes Trust. CONCLUSIONS: Rigorous instrument development is important for creating valid, reliable, and responsive disease-specific questionnaires. As a direction for future instrument development, an increased focus on qualitative research to ensure patient input may help to better conceptualize and operationalize the variables most relevant to head and neck cancer surgery patients. In addition, the use of alternative methods of psychometric data analysis, such as Rasch, may improve the value of health measurement in clinical practice for individual patients

OBJECTIVES/HYPOTHESIS: The term idiopathic pseudotumor (IP) refers to a nonspecific, nonneoplastic inflammatory process without identifiable local or systemic causes, which is one of the most common causes of intraorbital space-occupying lesions. Occasionally, orbital pseudotumors may extend to other areas of the skull base. Rarely, pseudotumors may present as a skull base mass with no involvement of the orbit. The ophthalmology literature has detailed reviews of IP as an intraorbital space-occupying lesion, but lesions involving only the skull base and sparing the orbit are rare in the literature. We present a review of our experience with six patients with extraorbital skull base pseudotumor and a review of the relevant literature. METHOD: Retrospective case study. RESULTS: We treated six patients with extraorbital skull base pseudotumor between 1996 and 2004. Four patients had lesions in the pterygopalatine and/or infratemporal fossae, and two patients had lesions in the superior aspect of the parapharyngeal space. Five patients had excellent initial response to steroids. Two of the pseudotumors recurred. One patient partially responded to steroids and is currently stable with limited disease. Our literature review demonstrated 16 previously published reports of IP of the skull base sparing the orbit. CONCLUSIONS: A well-documented intraorbital lesion, inflammatory pseudotumor may present outside the orbit. Treatment of IP of the skull base is controversial and may involve corticosteroids or surgical resection, or both. Other chemotherapeutic agents and radiotherapy may be considered in steroid-resistant patients. Pathological subtype, ease and safety of resection, safety of high-dose corticosteroid use, the surgeon's comfort, and the patient's preference must be included in the decision-making process for treatment

The concept of a totally implantable cochlear implant (TICI) offers the following advantages over the present generation of semi-implantable cochlear implants. These advantages include (1) cosmetics: deafness can be "hidden," because there is no external hardware during use; (2) no external hardware (e.g., cables, speech processor) to fail or be damaged; and (3) hearing possible 24/7, during sleep, in the shower, and while swimming. The TICI would incorporate all of the current external hardware within the buried device itself. There would also have to be external hardware for recharging the batteries and to serve other important diagnostic and functional purposes. All of this must be accomplished safely, without sacrificing performance.

CONCLUSIONS: Guild's initial 231 word report was the source of a stream of positive consequences; the glomus story is a paradigm of the utility of basic science. BACKGROUND: The glomus tumor has had a number of different names, including glomus jugulare, glomus tympanicum, nonchromaffin paraganglioma, and carotid body tumor. Although they have occurred throughout the ages, glomus tumors were neither recognized nor understood until Harry Rosenwasser read Stacy Guild's report of 1941. MATERIALS AND METHODS: The pertinent literature from the 18th century to the present was reviewed. RESULTS: Stacy Guild's pursuit of basic scientific knowledge laid the foundation for a chain of clinical and scientific advances that continue to the present and will continue to have positive effects into the future. Guild's brief basic science note of 1941 was used through the scholarship of Rosenwasser to define a clinical entity that had not been recognized. This new nosology, rapidly adopted worldwide, provided a biological basis for the rational grouping of patients and analysis of their ills. Subsequent to this, it was noted that many of these tumors occurred in families, apparently transmitted as an autosomal dominate but occurring primarily in the males. Further study based on these observations led to the identification of a genetic mechanism of inheritance: genomic imprinting. A further advance of the synergetic relationship between the environment - oxygen tension/altitude - and the mutation explains Guild's 1953 observations that all patients, without any sexual predominance, have glomus bodies but not all have tumors.