Faculty Bibliography

OBJECTIVES/HYPOTHESIS: Hurthle cell tumors are a variant of follicular cell neoplasms. The purpose of the study was to determine the reliability of intraoperative frozen-section analysis for diagnosing Hurthle cell carcinoma and Hurthle cell neoplasm and to evaluate age, gender, and tumor size differences in the incidence of Hurthle cell carcinoma. STUDY DESIGN: Retrospective chart review. METHODS: The records of all patients undergoing thyroid surgery at Long Island Jewish Medical Center (Long Island Campus of the Albert Einstein College of Medicine, New Hyde Park, NY) from 1990 to 2000 were reviewed. Patients were identified whose final pathological finding was Hurthle cell neoplasm or Hurthle cell carcinoma. Age at diagnosis, gender, tumor size, and correlation between frozen-section analysis and final pathological finding was determined. RESULTS: One hundred sixteen patients had Hurthle cell tumors on final pathological finding (49 had Hurthle cell carcinoma and 67 had Hurthle cell neoplasm). Eleven of these patients had incidental papillary carcinoma. There were 24 men and 92 women. Sixty-seven percent of the men (16 of 24) and 36% of the women (33 of 92) had Hurthle cell carcinoma on final pathological finding. The mean ages for Hurthle cell neoplasm and Hurthle cell carcinoma groups were 53 (median age, 50 y) and 58 years (median age, 61 y), respectively. One hundred eleven patients had intraoperative frozen-section analysis. Of the 49 patients with Hurthle cell carcinoma, 9 (19%) were diagnosed by frozen-section analysis, 36 (75%) had indeterminate frozen-section analysis, 3 (6%) were discovered to have papillary carcinoma on frozen-section analysis, and 1 did not have a frozen-section analysis. Multivariate analysis indicated that size correlated with malignancy and that gender did not (P =.0015). CONCLUSIONS: In the study population, only 19% of patients were discovered to have Hurthle cell carcinoma on frozen-section analysis. Sixty-seven percent of men with Hurthle cell neoplasm had malignancies, compared with 36% of women, and this difference was statistically significant

OBJECTIVE: Ionized field ablation, or coblation-assisted subtotal tonsillectomy, has been described as a new alternative technique for the management of tonsillar disease. This study was designed to review the incidence of complications in patients undergoing this procedure. STUDY DESIGN: A 10-surgeon retrospective chart review of the intraoperative and postoperative complications of patients undergoing ionized field ablation subtotal removal of tonsils was performed. Postoperative pain, dietary restrictions, and activity level were not reviewed. RESULTS: Of the 528 patients who underwent ionized field ablation of their tonsils, the incidence of intraoperative and postoperative complications compared favorably with those reported in retrospective studies in the literature for traditional subcapsular tonsillectomy. Significant postoperative bleeding occurred in less than 1%, and only 1 patient required surgical control of bleeding in the operating room. No patients required transfusions of any blood products. CONCLUSIONS: Ionized field ablation subtotal tonsillectomy may offer an alternative to traditional subcapsular tonsillar surgery with a decreased incidence of postoperative complications. Further study is necessary to establish the complication rate of this technique

The consequences of deafness on the central auditory nervous system have been examined at many levels, from molecular to functional. However, there has never been a direct and selective measurement of excitatory synaptic function following total hearing loss. In the present study, gerbils were deafened at postnatal day 9, an age at which there is no deafferentation-induced cell death of ventral cochlear nucleus neurons. One to five days after bilateral cochlear ablation, the amplitude of evoked excitatory postsynaptic currents (EPSC) was measured with whole-cell voltage-clamp recordings in an inferior colliculus (IC) brain slice preparation in response to electrical stimulation of the ipsilateral lateral lemniscus (LL) or the commissure of the inferior colliculus (CIC). Deafness resulted in larger LL- and CIC-evoked EPSC amplitudes and durations. This result was observed at a depolarized holding potential. In addition, deafness caused a decrease in excitatory neurotransmitter release at the LL pathway, as assessed with a paired-pulse stimulation protocol. In contrast to its effect on excitatory synapses, bilateral cochlear ablation reduced inhibitory synaptic strength in IC neurons. The effects included a postsynaptic decrease in IPSC conductance, a 25-mV depolarization in the IPSC equilibrium potential and a decrease of neurotransmitter release. Thus normal innervation differentially affects excitatory and inhibitory synaptic strength in IC neurons, and these changes may contribute to alterations in auditory coding properties following sensory deprivation

OBJECTIVE: To provide preliminary clinical data regarding endoscopically placed nitinol stents for children with tracheal obstruction as a temporizing measure to allow for trach tube decannulation while awaiting growth to allow for tracheal resection. METHODS: This case series describes the experiences of two children (ages 5 and 15) who were dependent upon tracheotomy because of acquired tracheal obstruction. Both patients had combined tracheomalacia and tracheal stenosis. After failing tracheoplasty with rib graft augmentation both patients suffered from extensive tracheal disease, which was too long to allow for immediate tracheal resection. INTERVENTION: Endoscopic placement of nitinol stents in the obstructed tracheal segment using fluoroscopic guidance. All tracheotomy tubes were removed immediately after successful stent deployment with the patient still under general anesthesia. RESULTS: Four stents were placed in total. The first patient's initial stent was too narrow and was, therefore, removed and replaced at a later date with a larger diameter stent. The second patient experienced distal migration of his initial stent requiring stent removal and replacement at a later date. Both patients remain successfully decannulated (follow-up, 25 and 26 months) and are currently living more normal lives as they grow and await tracheal resection. CONCLUSION: Preliminary use of nitinol stents for pediatric tracheal obstruction has enabled successful decannulation in two children with complicated airways. Our results with this series of patients suggest that nitinol stents can be safely used in children as a temporizing measure until tracheal resection can be safely performed. With this approach children can live free from the hassles of trach care, social isolation and peer ridicule. Limited pediatric experience exists in the literature about nitinol stents. Thus, our experience with stent selection and placement will help others avoid problems encountered in this initial series

Objective To assess the correlation between changes in spin-lattice relaxation in the rotating frame (T(1rho)) and proteoglycan (PG) loss from bovine articular cartilage and to demonstrate the feasibility of performing T(1rho) MR imaging on a 1.5T clinical scanner. Design MR relaxation times (T(1rho), T(2) and T(1)) were measured from excised cartilage plugs (N=3) before and after two sequential digestions with trypsin on a 2T whole-body magnet. Proteoglycan and collagen loss induced by the trypsin digestion was measured using standard biochemical techniques. The correlation between changes in relaxation times and PG loss were tested with regression analysis. T(1rho) MRI was also performed on a clinical 1.5T MRI system to determine whether the spatial distribution of PG loss could be detected. The MRI results were compared with histology sections of native and PG-depleted tissue. Results Increase in T(1rho) relaxation times correlated with PG loss (R(2)=0.81). T(1rho) measurements alone were indicative of PG loss (R(2)=0.8), the addition of T1 and T2 data into the statistical model did not improve the correlation substantially (R(2)=0.83). T(1rho)-weighted imaging demonstrated a hyperintense lamina at the articular surface of the digested tissue, which was subjected to trypsin digestion that correlated with a superficial zone of PG loss observed on histological sections. Conclusion The results of this study demonstrate that T(1rho) relaxation changes are correlated with PG loss in vitro. Furthermore, T(1rho) measurements alone can be used to indicate PG loss data. T(1rho) MRI may thus be developed into a useful adjunct to existing techniques for the evaluation of cartilage disease.

BACKGROUND AND PURPOSE: In evaluating intracranial tumors, a safe low-cost alternative that provides information similar to that of digital subtraction angiography (DSA) may be of interest. Our purpose was to determine the utility and limitations of a combined MR protocol in assessing (neo-) vascularity in intracranial tumors and their relation to adjacent vessels and to compare the results with those of DSA. METHODS: Twenty-two consecutive patients with an intracranial tumor who underwent preoperative stereoscopic DSA were examined with contrast-enhanced dynamic T2*-weighted perfusion MR imaging followed by a T1-weighted three-dimensional (3D) MR study (volumetric interpolated brain examination [VIBE]). The maximum relative cerebral blood volume (rCBV) of the tumor was compared with tumor vascularity at DSA. Critical vessel structures were defined in each patient, and VIBE images of these structures were compared with DSA findings. For full exploitation of the 3D data sets, maximum-intensity projection algorithms reconstructed in real time with any desired volume and orientation were used. RESULTS: Tumor blush scores at DSA were significantly correlated with the rCBV measurements (r = 0.75; P <.01, Spearman rank correlation coefficient). In 17 (77%) patients, VIBE provided all relevant information about the venous system, whereas information about critical arteries were partial in 50% of the cases and not relevant in the other 50%. CONCLUSION: A fast imaging protocol consisting of perfusion MR imaging and a volumetric MR acquisition provides some of the information about tumor (neo-) vascularity and adjacent vascular anatomy that can be obtained with conventional angiography. However, the MR protocol provides insufficient visualization of distal cerebral arteries

OBJECTIVE: Performing stapedotomy in cases of tympanosclerotic stapes fixation is controversial. The procedure is traditionally considered to carry a high risk of postoperative sensorineural hearing loss. The aim of this study was to report the hearing results in surgically treated cases of stapes fixation. STUDY DESIGN: A retrospective review of tympanosclerosis of the oval window with stapes fixation. SETTING: The study was performed at the Jean Causse Ear Clinic in Clombiers, France. PATIENTS: Sixty-five patients who underwent surgery for tympanosclerotic stapes fixation between January 1992 and October 1999. INTERVENTION: Stapedotomy with vein graft interposition and reconstruction with a Teflon piston, or a total prosthesis in cases of incudal erosion. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric evaluation using conventional audiometry. Air-bone gap, bone conduction threshold, air conduction threshold, and Glasgow Benefit Plot were measured. RESULTS: Postoperative air-bone gap closure to within 10 dB was achieved in 39% of cases. An air-bone gap less than 20 dB was obtained in 70% of cases. Significant postoperative improvement of air conduction thresholds, more than 20 dB, was found in 46% of cases. The postoperative bone conduction thresholds were unchanged in 92% of cases. No significant sensorineural hearing loss was seen in this series. CONCLUSION: This series demonstrates that safe and successful stapedotomy is possible if certain rules are respected.

Image Analysis, a complicated field still in the early stages of application to Pathology, has the capability of rendering major contributions to the diagnosis, prognosis, and management of malignancies of the breast. The present review summarizes the main problems and the general approach to the use of this technique for quantitating immunohistochemical stain results, obtaining DNA histograms, and making de novo diagnoses in routine materials of the Pathology service. In the case of diagnosis, the main steps are sampling, segmentation, and measures of chromatin texture. Currently, the limiting factor for all routine applications of image analysis is probably the absence of a reliable automatic nuclear segmentation

PURPOSE: The purpose of this project was to evaluate a novel technique for inducing osteogenesis through periosteal distraction in a rabbit model. MATERIALS AND METHODS: A periosteal distraction device was rigidly fixed to the lateral surface of the mandible in 10 adult rabbits. Periosteal distraction was started 7 days after placement of the periosteal distraction device. The periosteum was distracted 7 mm over 15 days. The unoperated, contralateral side of the mandible served as the control. The animals were killed at postoperative days 28, 35, 42, and 56. The specimens were then fixed, decalcified, and stained with hematoxylin and eosin. Histologic examination and histomorphometric analysis were performed on all specimens. RESULTS: Nine of 10 periosteal distraction devices remained rigidly fixed to the lateral surface of the mandible. On postoperative day 28, the histologic specimen from the experimental side showed periosteal proliferation and an increase in the number of osteoblasts. On postoperative days 35, 42, and 56, the experimental side showed an increase in the number of osteocytes per unit area, collagen fibers parallel to the vector of distraction, islands of osteoblasts surrounded by newly formed bone, and maturation of bone. An average of 2.86 +/- 0.56 mm of new bone height was formed. CONCLUSION: We report on a novel technique for generating bone by periosteal distraction. Our histologic analysis showed proliferation of the periosteum, an increase in the number of osteoblasts and osteogenesis

Acoustic analysis of a reading passage was used to identify the abnormal phonatory events associated with adductor spasmodic dysphonia (ADSD) pre- and postinjection of Botulinum Toxin A (Botox). Thirty-one patients (age 22 to 74 years) diagnosed with ADSD were included for study. All patients were new recipients of Botox, and the examination of their voice occurred before and after their initial injection of Botox. Acoustic events were identified from reading samples of the Rainbow Passage produced by each of the patients. These events were examined from sentences containing primarily voiced sound segments. Dependent variables included the number of phonatory breaks, frequency shifts, and aperiodic segments--all variables previously defined by the investigators. Additionally, calculated variables were made of the percentage of time these events occurred relative to the duration of the cumulative voiced segments. A sex- and age-matched control group (+/-2 years) was included for statistical comparison. Results indicated that those with ADSD produced more aberrant acoustic events than the controls. Aperiodicity was the predominant acoustic event produced during the reading, followed by frequency shifts and phonatory breaks. Within the ADSD group, the number of atypical acoustic events decreased following Botox injection. It is important that the occurrence of specific abnormal acoustic events was sufficient to differentiate the disordered speakers from the controls following as well as preceding initial Botox injection, as indicated by discriminant function analysis. This paper complements our previous work using this acoustic analysis method for defining the abnormal events present in the voice of those with ADSD and further suggests that these measures can be used in conjunction with perceptual impressions to differentiate speakers on the basis of initial severity