Faculty Bibliography

The authors present a modification to a previously reported supraorbital craniotomy procedure that is smaller, simpler, safe, and cosmetically pleasing. Minimal brain retraction is used without compromising the surgical exposure of the orbital roof, floor of the anterior fossa, and the parasellar region to treat tumoral lesions that are located medial to the ipsilateral optic nerve as well as aneurysms of the anterior communicating artery.

The anterior clinoid process (ACP), located on the skull base, is a relatively small structure, although its removal provides enormous gain in facilitating the management of lesions--either tumors or aneurysms--in the paraclinoid region and upper basilar artery. The extensive surgical field gained contributes to safer exposure of the neurovascular elements in the vicinity while avoiding excessive and hazardous retraction of the brain. In this report the authors present a technically simpler avenue for performing an extradural anterior clinoidectomy after reviewing the anatomy of the ACP and its anatomical variations. Additionally, the original Dolenc procedure and its subseqtient derivatives are compared and contrasted to the authors' simpler and less laborious technique. Different clinical situations in which to use the procedure are described based on the authors' experience from 60 cases (40 aneurysm cases and 20 tumor cases) during a 4-year period.

The authors report on a surgical technique involving a one-piece osteoplastic bone flap, which incorporates the frontal, temporal, and lateral portions of the orbital rim as a technically simpler alternative to the standard orbitozygomatic (OZ) craniotomy. The orbital rim component extends just laterally from the supraorbital foramen/notch to the frontozygomatic suture. This craniotomy obviates the need for removing the zygoma and has evolved from the authors' experience in more than 200 patients with a variety of pathological lesions, both vascular and tumorous. The osteoplastic aspect of this technique was initially evaluated in 14 cadaveric sites in seven heads dissected prior to implementing this procedure clinically. The osteoplastic bone flap minimally obstructs the surgical view and provides all the advantages of a standard OZ craniotomy. Temporalis muscle atrophy leading to temporal hollowing is avoided, a bone union to the calvaria is improved, and the possibility of bone infection is decreased. The osteoplastic component of the technique adds to the improved long-term cosmesis and warrants active consideration in the art of neurosurgery.

The purpose of this retrospective study was to evaluate the extent to which an early Le Fort III osteotomy affects the position and eruption of the permanent maxillary first and second molars. To test the null hypothesis that there are no changes in eruption patterns, 31 patients diagnosed with craniosynostoses (13 with Crouzon's syndrome, nine with Apert's syndrome, eight with Pfeiffer's syndrome, and one with Carpenter's syndrome) with a mean age at the time of surgery of 5.3 +/- 1.3 years were studied. All patients underwent a Le Fort III osteotomy performed by a single surgeon to correct the anatomical deformity for functional and psychosocial reasons. Eighteen patients with craniosynostoses who had not been operated on (11 with Crouzon's syndrome, four with Apert's syndrome, and three with Pfeiffer's syndrome) served as controls; they had a mean age of 21.2 +/- 9.5 years. First and second molar positions and eruption patterns were assessed separately on panoramic radiographs by three observers. For the patients who underwent surgery, long-term evaluation showed that although 79 percent of all first molars erupted compared with 100 percent for the control group (p < 0.001), only 18 percent of all second permanent molars erupted compared with 89 percent for the control group (p < 0.0001). The authors conclude that in a significant minority of cases, early Le Fort III osteotomy affects first molar eruption, whereas the probability of second molar eruption is significantly decreased in the majority of cases. Therefore, Le Fort III osteotomy sites should be positioned distal to the second molar tooth buds. If this is not possible, patients, parents, and dental professionals should be made aware of these early postosteotomy sequelae so that later treatment planning can be enhanced.

BACKGROUND AND OBJECTIVE: Patients who require surgery for chronic otitis media with perforation and cholesteatoma frequently provide no residual tympanic membrane that is usable in grafting procedures. A novel technique of total tympanic membrane reconstruction (TTMR) is described that maximizes perforation closure rate in these situations while minimizing mucosalization, incomplete healing, and anterior blunting. The specific aim of this report is to assess the safety and efficacy of TTMR and to compare the results obtained with AlloDerm compared with temporalis fascia as a grafting material. METHODS: The records of 50 patients operated within the years 1999 and the 2004 were reviewed. TTMR with intact canal wall was performed in all cases. Both clinical and audiometric data were analyzed. RESULTS: Overall perforation closure rate was 92%. There was no statistical significance in closure rate when grafting with AlloDerm versus temporalis fascia. A statistically significant shortened healing time was observed with AlloDerm grafting. CONCLUSIONS: TTMR is a highly effective and safe technique

OBJECTIVES: As a result of universal newborn hearing screening and improved evaluation tools, many children with severe to profound hearing loss are being diagnosed as infants. This affords the opportunity to provide these children access to cochlear implantation, although medical and audiologic challenges must be addressed. The purpose of this study was to investigate the safety and efficacy of cochlear implantation in children who are younger than 1 year. METHODS: A prospective study was conducted of 18 children who had confirmed severe to profound sensorineural hearing loss and received cochlear implants at our medical center before 12 months of age. The length of device usage ranged from 6 months to 4 years, 5 months. The main outcomes measured were perioperative and postoperative surgical/medical aspects, the Infant-Toddler Meaningful Auditory Integration Scale and age-appropriate phoneme, and word and sentence recognition tests, when appropriate. RESULTS: All children had full insertions of the electrode array without surgical complications and are developing age-appropriate auditory perception and oral language skills. CONCLUSIONS: Early implantation is feasible and beneficial in some children who are younger than 12 months and should be considered with attention to variables involved in the decision-making process, including possible increased surgical risk, skull size and scalp thickness, and mastoid development

OBJECTIVES: Consultations for tracheotomy are often sought on aged and severely ill patients with respiratory insufficiency. This patient population has high short-term mortality rates and is difficult to stratify on the basis of expected outcome. We examined whether APACHE III (Acute Physiology and Chronic Health Evaluation III) scores or neurologic status assessment (NSA) scores in sedated individuals are predictive of outcome. METHODS: We performed a retrospective study examining aged patients who underwent tracheotomy for respiratory insufficiency and prolonged intubation. The APACHE III scores (n = 30) and NSA (based on a modified Glasgow Coma Scale) scores (n = 37) were calculated before tracheotomy. All patients were mildly sedated. Using APACHE III and NSA scores as predictor variables and using death and ability to be weaned from the ventilator as outcome variables, we performed a Kaplan-Meier survival analysis and a Cox proportional hazard regression. RESULTS: The APACHE III was not significantly predictive of either outcome. Higher NSA scores were associated with increased survival rates (log rank = 19.7, p < .0001) and longer median survival (88 days versus 16 days for lower scorers). Higher NSA scores also predicted a higher rate of ventilator independence. CONCLUSIONS: Neurologic function in sedated patients (and not APACHE III scores) can be used to stratify aged individuals with respiratory insufficiency on the basis of expected outcome

PURPOSE OF REVIEW: Degeneration of spiral ganglion neurons following hair cell loss carries critical implications for efforts to rehabilitate severe cases of hearing loss with cochlear implants or hair cell regeneration. This review considers recently identified neurotrophic factors and therapeutic strategies which promote spiral ganglion neuron survival and neurite growth. Replacement of these factors may help preserve or regenerate the auditory nerve in patients with extensive hair cell loss. RECENT FINDINGS: Spiral ganglion neurons depend on neurotrophic factors supplied by hair cells and other targets for their development and continued survival. Loss of this trophic support leads to spiral ganglion neuron death via apoptosis. Hair cells support spiral ganglion neuron survival by producing several peptide neurotrophic factors such as neurotrophin-3 and glial derived neurotrophic factor. In addition, neurotransmitter release from the hair cells drives membrane electrical activity in spiral ganglion neurons which also supports their survival. In animal models, replacement of peptide neurotrophic factors or electrical stimulation with an implanted electrode attenuates spiral ganglion neuron degeneration following deafferentation. Cell death inhibitors can also preserve spiral ganglion neuron populations. Preliminary studies show that transfer of stem cells or neurons from other ganglia are two potential strategies to replace lost spiral ganglion neurons. Inducing the regrowth of spiral ganglion neuron peripheral processes to approximate or contact cochlear implant electrodes may help optimize signaling from a diminished population of neurons. SUMMARY: Recent studies of spiral ganglion neuron development and survival have identified several trophic and neuritogenic factors which protect these specialized cells from degeneration following hair cell loss. While still preliminary, such strategies show promise for future clinical applications

To analyze the impact of resection margin status and histologic prognosticators on local recurrence (LR) and overall survival (OS) for patients with oral squamous cell carcinoma (OSCC). This study was both retrospective and prospective in design. Cohort 1 refers to the entire group of 292 patients with OSCC. The slides from the earliest resection specimens from Cohort 1 were examined in an exploratory manner for multiple parameters. Cohort 2 refers to a subset of 203 patients, who did not receive any neoadjuvant therapy and had outcome data. Cohort 3 represents a subset of Cohort 2 (n = 168) wherein the histologic resection margin status could be reconfirmed. Cohort 4 refers a subset of 85 patients with tongue/floor of mouth tumors. Margin status was designated as follows: group 1, clearance of > or =5 mm with intraoperative analysis, no need for supplemental margins (n = 46); group 2, initial margins were measured as <5 mm during intraoperative frozen section; supplemental resection margins were negative on final pathology (n = 73); group 3, the final pathology revealed resection margins <5 mm (n = 30); group 4, the final pathology revealed frankly positive resection margins (n = 19). The endpoints of LR and OS were queried with respect to T stage, tumor site, margin status, and numerous histologic variables, by Cox regression and Kaplan-Meier survival analyses. Tumor stage (T) was significantly associated with LR (P = 0.028). Kaplan-Meier analysis for stage and for intraoral site was significantly associated with LR for T4 tumors. The increased likelihood of LR was higher for T4 OSCC of the buccal mucosa (75%), sinopalate (50%), and gingiva (100%) compared with mobile tongue (27%), and oropharynx (13%) (P = 0.013). Margin status was not associated with LR or OS (Cohort 3). This was so when all tumors were grouped together and when separate analyses were performed by tumor stage and oral subsite. No significance was demonstrated when margin status was examined for patients with similar treatment (surgery alone or surgery with adjuvant RT). However, the administration of adjuvant RT did significantly increase local disease-free survival (P = 0.0027 and P = 0.001 for T1 and T2 SCC, respectively). On exploratory analyses of histologic parameters, worst pattern of invasion was significantly associated with LR (P = 0.015) and OS (P < 0.001). Perineural invasion involving large nerves (>1 mm) was associated with LR (P = 0.005) and OS (P = 0.039). Limited lymphocytic response was also significantly associated with LR (P = 0.005) and OS (P = 0.001). When used as covariates in a multivariate Cox regression model, worst pattern of invasion, perineural invasion, and lymphocytic response were significant and independent predictors of both LR and OS, even when adjusting for margin status. Thus, these factors were used to generate our risk assessment. Our risk assessment classified patients into low-, intermediate-, or high-risk groups, with respect to LR (P = 0.0004) and OS (P < 0.0001). This classification retained significance when examining patients with uniform treatment. In separate analyses for each risk group, we found that administration of adjuvant radiation therapy is associated with increased local disease-free survival for high-risk patients only (P = 0.0296) but not low-risk or intermediate-risk patients. Resection margin status alone is not an independent predictor of LR and cannot be the sole variable in the decision-making process regarding adjuvant radiation therapy. We suggest that the recommendation for adjuvant radiation therapy be based on, not only traditional factors (inadequate margin, perineural invasion, bone invasion) but also histologic risk assessment. If clinicians want to avoid the debilitation of adjuvant radiation therapy, then a 5-mm margin standard may not be effective in the presence of high-risk score

The coexistence of lung cancer and glomerular lesion is not commonly reported. Malignancy-related glomerulopathy is commonly membranous glomerulonephritis. Other glomerulopathies are seldom reported. We report two cases presenting with non-small-cell lung cancer, acute renal failure and nephrotic syndrome secondary to membranoproliferative glomerulonephritis and amyloidosis