Faculty Bibliography

We studied adaptations in nucleus accumbens opioidergic circuitry mediating noxious stimulus-induced antinociception (NSIA) in rats withdrawing from chronic morphine administration. Although the magnitude of NSIA in withdrawing rats was similar to that observed in naive rats despite the tolerance of withdrawing rats to the antinociceptive effects of acutely administered morphine, the involvement of nucleus accumbens opioid receptors in NSIA in withdrawing rats was different from previous observations in both naive and tolerant rats. In withdrawing rats intra-accumbens administration of the mu-opioid receptor antagonist Cys2, Tyr3, Orn5, Pen7 amide (CTOP), but not the delta-receptor antagonist naltrindole, blocked NSIA. Both antagonists blocked NSIA in the naive state, but neither was effective in tolerant rats. Also, intra-accumbens administration of the mu-agonist [D-Ala2, N-Me-Phe(4,) Gly5-ol]-enkephalin (DAMGO) alone was sufficient to induce antinociception in withdrawing rats, whereas a combination of both mu- and delta-receptor agonists (ie, DAMGO and D-Pen(2,5)-enkephalin [DPDPE], respectively) is required to induce antinociception in naive rats. The delta- agonist DPDPE was without effect in the withdrawing rat, alone or when combined with DAMGO. Thus, although the magnitude of NSIA does not differ significantly among the 3 states, it is mediated by both mu- and delta-receptors in the naive rat, mu- but not delta-receptors in the withdrawing rat, and neither receptor type in the morphine tolerant rat. These changes may result from different degrees of tolerance, with delta-receptors being the most sensitive; however, it is not known how these changes occur without affecting the magnitude of the resultant antinociception

BACKGROUND: An explanation for the predominance of injuries to lingual nerves over those to inferior alveolar nerves as a result of inferior alveolar nerve blocks may be due to the nerves' fascicular pattern. A unifascicular nerve may be injured more easily than a multifascicular nerve. METHODS: The authors unilaterally dissected lingual and inferior alveolar nerves from 12 cadavers. They cut the specimens 2 millimeters above the lingula for both the lingual nerve and inferior alveolar nerve and opposite the site of the middle of the third molar for the lingual nerve, and they counted the number of fascicles at each site. RESULTS: For the lingual nerve at the lingula, the mean number of fascicles was three (range, one to eight). Four of the 12 nerves (33 percent) were unifascicular at this point. Opposite the third molar, the lingual nerve had a mean of 20 fascicles (range, six to 39). In every case, there were more fascicles in the third molar region than above the lingula in the same nerve. At the lingula, the inferior alveolar nerve had a mean of 7.2 fascicles (range, three to 14). CONCLUSION: This study may explain the observation that when an inferior alveolar nerve block causes permanent nerve impairment, the lingual nerve is affected about 70 percent of the time and the inferior alveolar nerve is affected only 30 percent of the time. In 33 percent of cases, the lingual nerve had only one fascicle at the lingula; a unifascicular nerve may be injured more easily than a multifascicular one. CLINICAL IMPLICATIONS: There is no known way to avoid the remote possibility of nerve damage resulting from an inferior alveolar nerve block. The lingual nerve may be predominantly affected because of its fascicular pattern

Massive sinonasal polyposis associated with skull base dehiscence and intracranial extension is a difficult disease to treat. Conventional transnasal or transfacial techniques can result in dural injury, cerebrospinal fluid (CSF) leak and infection. We describe our experience with a combined neurosurgical-endoscopic technique that protects the meninges. Five patients with massive sinonasal polyposis extending intracranially through skull base dehiscence were reviewed retrospectively. The minimum follow-up was 2 years. A frontal craniotomy was performed through a bicoronal approach. The dura was carefully separated from all infectious material at the floor of the anterior cranial fossa. The frontal lobe with the intact meninges was elevated off the anterior cranial floor. A sheet of blue plastic material was inserted under the frontal lobe from the craniotomy site to the planum sphenoidale. Next, a transnasal endoscopic ethmoidectomy, sphenoidectomy, and frontal sinusotomy were performed to remove the inflammatory processes. The blue plastic material was visible through any existing or potential skull base dehiscence, thus providing visual protection for the dura and brain. All gross disease was removed from the frontal, ethmoid, and sphenoid skull base regions in the 5 patients without dural injury. None of the patients developed a CSF leak or meningitis. Two patients developed recurrent polyposis limited to the sinuses without intracranial extension. The endoscopic craniofacial approach with the 'Blue-Sky' protective technique offers a safe method for completely removing massive sinonasal polyposis associated with an intracranial extension

BACKGROUND AND OBJECTIVES: Marginal mandibulectomy (MM) has been shown to provide an oncologically sound technique with preservation of function and cosmesis. We reviewed our experience with MM and analyzed oncologic and nononcologic complications. PATIENTS AND METHODS: Retrospective review of patients, with clinical and/or radiological evidence of tumor attached to the mandible without cortical erosion, who underwent vertical, horizontal, or oblique marginal mandibulectomy. Data collection included demographics; tumor characteristics; clinical and radiologic relation to the mandible; surgical technique, with attention to neck dissection and facial artery ligation; radiation therapy; osteoradionecrosis (ORN); fractures; and recurrence. RESULTS: Twenty-five patients underwent MM. Primary tumors included oral cavity (22), oropharynx (1). and metastatic neck tumor abutting the inferior/lateral border of the mandible (2). Two patients had local recurrence. Both had close soft tissue margins. Local control rate was 92%. Of 11 patients who had postoperative radiation to the primary site, 4 (36.4%) developed ORN, resulting in fractures in the mandibulectomy site in 2 of them. Two other patients developed early postoperative fractures: 1 patient had had previous radiation, and 1 patient had neck dissections with bilateral facial artery ligation and periosteal stripping. This poor technique led to necrosis of the remaining anterior mandible even before starting radiotherapy. Salvage segmental mandibulectomy was required in both patients. CONCLUSIONS: MM provides an oncologically sound approach to tumors abutting the mandible. Careful attention to preservation of the remaining periosteum and facial arteries will prevent immediate postoperative complications. However, ORN is an important long-term complication that should be taken into account

BACKGROUND: Treatment options for unilateral glottic carcinoma include radiation therapy, partial laryngectomy, and endoscopic cordectomy. We used partial laryngectomy with imbrication laryngoplasty (PLIL) for definitive treatment with curative intent in a select group of patients. STUDY DESIGN: Retrospective multicenter review of 24 patients treated with PLIL. Data collection included demographics, tumor characteristics, time to decannulation, time to oral food intake, local control, survival, voice result as judged by the physician, voice result as judged by the patient, and patient satisfaction. SETTING: Five academic medical centers. METHODS: PLIL includes a composite resection of the entire vocal fold, with its ligament, muscle, adjacent paraglottic tissues, and the adjacent block of thyroid cartilage. A neocord is reconstructed by imbricating the remaining thyroid cartilage strips and covering them with a false vocal fold flap. RESULTS: A total of 24 patients (T1, n = 13; T2, n = 10; and T3, n = 1) underwent PLIL. Median time to decannulation was 4 days, and median time to oral food intake was 5 days. Clear margins were achieved in 23 patients (96%). Follow-up ranged from 1 to 11 years (median duration of follow-up, 5.5 years). In the patients who had clear margins at the initial surgery, the rate of overall disease control was 100%. Voice quality was judged by the physician as good or excellent in 100% of the patients who underwent PLIL, and as better than typical hemilaryngectomy in 23 patients (96%). Twenty-three patients (96%) were satisfied with their voice quality. CONCLUSIONS: PLIL provides us with a single modality curative approach to unilateral glottic carcinoma. It also provides rapid recovery of oral and/or nasal airway and swallowing, excellent voice quality, and a disease-control rate similar to or better than other treatment modalities

PURPOSE: To determine both the efficacy and safety of the topical application of 50 mg penicillin G potassium troches (Cankercillin) in the treatment of minor recurrent aphthous stomatitis (RAS). STUDY DESIGN: The investigation used a phase 2 double-blind, randomized placebo-controlled trial with a no-treatment arm. Subjects with minor aphthous ulcers of duration <48 hours were followed for 1 week. The primary endpoint for efficacy was time (days) to complete ulcer resolution, and the secondary endpoint was time (days) to complete pain relief. RESULTS: Thirty-one, 33, and 36 subjects were randomized to the active treatment, placebo, and no-treatment arms, respectively. Baseline findings were heterogeneous across arms. Subjects who received penicillin G treatment had complete ulcer healing and pain relief significantly earlier than those in the placebo and no-treatment arms. No allergic reactions were observed. CONCLUSIONS: Topical penicillin G, by mechanisms which remain unclear, reduces the time of healing and pain relief of minor aphthous ulcers with minimal safety concerns. Larger phase 3 studies are necessary to confirm these findings

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.