Faculty Bibliography

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

The analysis of saliva has been proposed as a potentially rapid, non-invasive method to monitor and diagnose patients with oral disease. In this study we measured salivary endothelin-1 (ET-1) levels in patients diagnosed with oral squamous cell carcinoma (SCC) prior to treatment. We demonstrate significantly elevated salivary ET-1 levels in the oral SCC group (4.37+/-1.35pg/ml), relative to the control group (1.16+/-0.29pg/ml). ET-1 and ET-1 mRNA were also measured in oral SCC tissue specimens and compared to normal oral epithelial controls. The concentration of ET-1 in the oral SCC specimens was 17.87+/-4.0pg/ml and in the normal epithelial controls the concentration of ET-1 was 5.43+/-2.5pg/ml. ET-1 mRNA was significantly overexpressed in 80% (8/10) of the oral SCC specimens. Our results demonstrate the potential utility of salivary analysis for ET-1 levels to monitor patients at risk for oral SCC

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

BACKGROUND: The aim of this study was to determine the incidence, outcomes, and risk factors for synechia formation after endoscopic sinus surgery (ESS) and middle turbinate medialization with and without FloSeal. METHODS: A retrospective review was performed of patients who underwent primary ESS with middle turbinate medialization, with or without the placement of FloSeal. Medialization was performed with the placement of an absorbable conchopexy suture and silastic splint. Operative variables and outcomes were analyzed to identify risk factors for synechia formation. RESULTS: One hundred thirty-five patients underwent medialization alone and 37 patients underwent medialization with placement of FloSeal. Overall, synechia formation was noted in 16 patients (9.3%). A statistically significant higher incidence of synechia formation was noted in patients who underwent middle turbinate medialization with the placement of FloSeal versus medialization alone (18.9% versus 6.7%). The incidences of intraoperative complications (6.2% versus 4.7%) and postoperative complications (6.2% versus 7%) were similar between patients with and without synechia, respectively. Patients experiencing synechia, however, underwent a statistically significant higher rate of revision procedures (25% versus 5.1%). CONCLUSION: Despite adequate prevention with middle turbinate medialization, synechia formation after ESS may result in higher rates of revision procedures. The placement of FloSeal in conjunction with middle turbinate medialization may result in a higher incidence of synechia formation

OBJECTIVE: Common peroneal nerve (CPN) paresis or paralysis presents with weakness of the toe extensors as well as of the ankle dorsiflexors and evertors, causing foot drop and hypesthesia or paresthesia in the CPN distribution. Previous studies have shown associations with weight loss and leg crossing. Although CPN neuropathy has been described in cancer patients, it has not been described in head and neck cancer (HNC) patients specifically. Our objective was to describe a series of patients who developed CPN neuropathy during the course of their disease. MATERIALS AND METHODS: A retrospective review of the charts of patients with HNC and CPN neuropathy who were seen at our institution between 1995 and 2004 was performed. RESULTS: Four HNC patients with CPN neuropathy were identified. All had significant weight loss. One patient became symptomatic before treatment, 2 patients became symptomatic during treatment, and 1 patient developed foot drop 4 years after treatment when his free jejunal flap developed a stricture. Two patients had electrodiagnostic study findings that revealed conduction block at the fibular head and denervation of peroneal innervated muscles. Imaging studies revealed no evidence of metastatic disease in the lumbosacral region. All 4 patients improved after weight gain. CONCLUSIONS: Common peroneal nerve neuropathy may be seen in HNC patients. The CPN may be susceptible in weight loss because of the associated loss of subcutaneous tissue, which cushions the nerve from the fibular head. Consideration should be given to prevention, appropriate neurologic consultation, and patient counseling

Solitary fibrous tumors (SFTs) are unusual mesenchymal tumors that were first described as primary spindle-cell neoplasms of the pleura. These tumors have been described in many other locations, including the urogenital system, orbit, mediastinum, and upper respiratory tract. Twenty-two cases of an SFT of the paranasal sinuses and nasal cavity have been reported, but none described a malignant SFT extending through the anterior skull base. A 70-year-old man had a 6-month history of unilateral left-sided epiphora and nasal obstruction. Computed tomography and magnetic resonance imaging showed a large left-sided nasal cavity mass with extension into the left extraconal orbit and intracranial extension through the left cribriform plate and ethmoid roof. The patient underwent preoperative embolization of the internal maxillary artery and a subsequent anterior craniofacial resection via a midfacial degloving approach and a left anterior craniotomy. Histopathological analysis of the specimen was consistent with a malignant SFT

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

It is well known that discrimination response variability increases with stimulus intensity, closely related to Weber's Law. It is also an axiom that sensation magnitude increases with stimulus intensity. Following earlier researchers such as Thurstone, Garner, and Durlach and Braida, we explored a new method of exploiting these relationships to estimate the power function exponent relating sound pressure level to loudness, using the accuracy with which listeners could identify the intensity of pure tones. The log standard deviation of the normally distributed identification errors increases linearly with stimulus range in decibels, and the slope, a, of the regression is proportional to the loudness exponent, n. Interestingly, in a demonstration experiment, the loudness exponent estimated in this way is greater for females than for males