Faculty Bibliography

PURPOSE: This study evaluated the use of enucleation and cryosurgery in the management of odontogenic keratocysts. PATIENTS AND METHODS: This study involved a retrospective review of 26 patients. All of the patients received a combination of enucleation and cryosurgery. Postoperative follow-up consisted of clinical and radiographic examinations. RESULTS: Before enucleation and cryotherapy, 22 of the 26 patients had received previous treatment consisting of enucleation alone. The average time from initial treatment to recurrence was 6.2 years. Twenty-three cases occurred in the mandible, 22 in the posterior (proximal to the canine), and 1 in the anterior mandible. Three cases involved the maxilla. Three of the 26 patients (11.5%) developed a recurrence after treatment. The average time from treatment to recurrence in these 3 patients was 1.6 years (range, 1.2 to 1.9 years). The remaining 23 patients (88.5%) had no evidence of clinical or radiographic recurrence. The average time of follow-up was 3.5 years (range, 2.0 to 10.0 years). CONCLUSIONS: Based on these results, the combination of enucleation and liquid nitrogen cryotherapy may offer patients improved therapy in the management of odontogenic keratocysts

We sought to review our experience with salivary mucoepidermoid carcinoma (MEC) over two decades to confirm the validity and reproducibility of histologic grading and to investigate MIB-1 index as a prognosticator. Diagnosis was confirmed on 80 cases, and chart review or patient contact was achieved for 48 patients, with follow-up from 5 to 240 months (median 36 months). Immunohistochemistry with citrate antigen retrieval for MIB-1 was performed on a subset of cases. Kaplan-Meier survival curves were generated for each stage, site, and grade according to our proposed grading system. To address the issue of grading reproducibility, 20 slides were circulated among five observers, without prior discussion; slides were categorized as low-, intermediate-, or high-grade according to one's 'own' criteria, and then according to the AFIP criteria proposed by Goode et al.10 Weighted kappa (kappa) estimates were obtained to describe the extent of agreement between pairs of rating. The Wilcoxon signed rank test or the Friedman test as appropriate tested variation across ratings. There was no gender predominance and a wide age range (15-86 years, median 49 years). The two most common sites were parotid and palate. All grade 1 MECs presented as Stage I tumors, and no failures were seen for this category. The local disease failure rates at 75 months for grades 2 and 3 MEC were 30% and 70%, respectively. Tumor grade, stage, and negative margin status all correlated with disease-free survival (DFS) (p = 0.0091, 0.0002, and 0.048, respectively). The MIB index was not found to be predictive of grade. Regarding the reproducibility of grading, the interobserver variation for pathologists using their 'own' grading, as expressed by the kappa value, ranged from good agreement (kappa = 0.79) to poor (kappa = 0.27) (average kappa = 0.49). A somewhat better interobserver reproducibility was achieved when the pathologists utilized the standardized AFIP criteria (average kappa = 0.61, range 0.38-0.77). This greater agreement was also reflected in the Friedman test (statistical testing of intraobserver equality), which indicated significant differences in using one's own grading systems (p = 0.0001) but not in applying the AFIP 'standardized' grading (p = 0.33). When one's own grading was compared with the AFIP grading, there were 100 pairs of grading 'events,' with 46 disagreements/100 pairs. For 98% of disagreements, the AFIP grading 'downgraded' tumors. This led us to reanalyze a subset of 31 patients for DFS versus grade, for our grading schema compared with the AFIP grading. Although statistical significance was not achieved for this subset, the log rank value revealed a trend for our grading (p = 0.0993) compared with the Goode schema (p = 0.2493). This clinicopathologic analysis confirms the predictive value of tumor staging and three-tiered histologic grading. Our grading exercise confirms that there is significant grading disparity for MEC, even among experienced ENT/oral pathologists. The improved reproducibility obtained when the weighted AFIP criteria were used speaks to the need for an accepted and easily reproducible system. However, these proposed criteria have a tendency to downgrade MEC. Therefore, the addition of other criteria (such as vascular invasion, pattern of tumor infiltration [i.e., small islands and individual cells vs cohesive islands]) is necessary. We propose a modified grading schema, which enhances predictability and provides much needed reproducibility

OBJECTIVE: To describe and evaluate an ear piercing and earring retention method for individuals with metal hypersensitivity. SETTING: Private facial plastic surgery practice associated with a tertiary care medical center. METHODS: Thirty-one patients with a history of hypersensitivity to metallic jewelry (62 ears) underwent earlobe piercing with an intravenous catheter. RESULTS: None of the patients experienced an infection or hypersensitivity reaction. All patients were able to wear nickel-free earrings for short periods without using the shortened catheter. CONCLUSION: Using the distal shaft of an intravenous catheter as an earring post sheath is a safe and effective technique that allows hypersensitive individuals to wear earrings in pierced ears on a limited basis.

In many areas of the nervous system, excitatory and inhibitory synapses are reconfigured during early development. We have previously described the anatomical refinement of an inhibitory projection from the medial nucleus of the trapezoid body to the lateral superior olive in the developing gerbil auditory brain stem. Furthermore, these inhibitory synapses display an age-dependent form of long-lasting depression when activated at a low rate, suggesting that this process could support inhibitory synaptic refinement. Since the inhibitory synapses release both glycine and GABA during maturation, we tested whether GABA(B) receptor signaling could initiate the decrease in synaptic strength. When whole cell recordings were made from lateral superior olive neurons in a brain slice preparation, the long-lasting depression of medial nucleus of the trapezoid body-evoked inhibitory potentials was eliminated by the GABA(B) receptor antagonist, SCH-50911. In addition, inhibitory potentials could be depressed by repeated exposure to the GABA(B) receptor agonist, baclofen. Since GABA(B) receptor signaling may not account entirely for inhibitory synaptic depression, we examined the influence of neurotrophin signaling pathways located in the developing superior olive. Bath application of brain-derived neurotrophic factor or neurotrophin-3 depressed evoked inhibitory potentials, and use-dependent depression was blocked by the tyrosine kinase antagonist, K-252a. We suggest that early expression of GABAergic and neurotrophin signaling mediates inhibitory synaptic plasticity, and this mechanism may support the anatomical refinement of inhibitory connections

PURPOSE: To describe a condition that occurs following an upper respiratory illness, which represents injury to various branches of the vagus nerve. Patients with this condition may present with breathy dysphonia, vocal fatigue, effortful phonation, odynophonia, cough, globus, and/or dysphagia, lasting long after resolution of the acute viral illness. The patterns of symptoms and findings in this condition are consistent with the hypothesis that viral infection causes or triggers vagal dysfunction. This so-called postviral vagal neuropathy (PVVN) appears to have similarities with other postviral neuropathic disorders, such as glossopharyngeal neuralgia and Bell's palsy. MATERIALS AND METHODS: Five patients were identified with PVVN. Each patient's chart was reviewed, and elements of the history were recorded. RESULTS: Each of the 5 patients showed different features of PVVN. CONCLUSIONS: Respiratory infection can trigger or cause vocal fold paresis, laryngopharyngeal reflux, and neuropathic pain

The purpose of this article is to describe an approach to reconstruction of the larynx after vertical partial laryngectomy with removal of the ipsilateral arytenoid cartilage. This method addresses the problem of postoperative posterior glottal incompetence (aphonia with or without aspiration). The technique involves resection of the ipsilateral half of the cricoid cartilage, use of an inferiorly based strap muscle flap for vocal fold reconstruction, and placement of a customized stent. This technique may be used at the time of the primary cancer extirpation or as a secondary rehabilitative procedure. Generally, patients who have undergone this procedure have had minimal postoperative breathiness with good phonatory and airway function. We recommend this reconstructive technique for patients with large posterior defects following hemilaryngectomy

BACKGROUND: Laryngeal electromyography (LEMG) is a valuable diagnostic/prognostic test for patients with suspected laryngeal neuromuscular disorders. OBJECTIVE: To report our experience with diagnostic LEMG at the Center for Voice Disorders of Wake Forest University and to evaluate the impact of LEMG on clinical management. METHODS: Retrospective chart review of 415 patients who underwent diagnostic LEMG over a 5-year period (1995-1999). RESULTS: Of 415 studies, 83% (346 of 415) were abnormal, indicating a neuropathic process. LEMG results altered the diagnostic evaluation (eg, the type of radiographic imaging) in 11% (46 of 415) of the patients. Unexpected LEMG findings (eg, contralateral neuropathy) were found in 26% (107 of 415) of the patients, and LEMG results differentiated vocal fold paralysis from fixation in 12% (49 of 415). Finally, LEMG results altered the clinical management (eg, changed the timing and/or type of surgical procedure) in 40% (166 of 415) of the patients. CONCLUSIONS: LEMG is a valuable diagnostic test that aids the clinician in the diagnosis and management of laryngeal neuromuscular disorders

Nasal steroid sprays have become a mainstay in the medical treatment of chronic allergic and nonallergic rhinosinusitis. Their effect is dependent on the topical application of the steroid to the nasal mucous membrane. When used properly, the spray should be aimed toward the lateral nasal wall. Specifically, 2 anatomic sites linked to the symptomatology of chronic rhinosinusitis, the inferior turbinate and the middle meatus, are targeted. We conducted a prospective study in patients who regularly use a topical nasal steroid spray to determine the actual distribution of the medication on the nasal mucosa. Participants in the study were given a sample bottle of an aqueous steroid nasal spray that had been colored with a nontoxic food dye, and were instructed to use the spray in their usual manner. Bilateral anterior rhinoscopy and fiberoptic nasal endoscopy were performed after application of the spray to determine its location on the nasal mucosa. The intranasal examination was repeated after 15 minutes to allow for redistribution of the medication by mucociliary transport. Findings were recorded after each examination and are discussed along with potential clinical implications. (18 ref) <2>

OBJECTIVE: This study evaluates whether patients with severe sensory deficits in the hypopharynx are at increased risk for aspiration and determines the relationship between pharyngeal muscular weakness and hypopharyngeal sensory deficits. STUDY DESIGN AND SETTING: Forty patients with dysphagia who underwent flexible endoscopic evaluation of swallowing with sensory testing were prospectively divided into 2 groups. One group included patients with severe sensory deficits determined by an absent laryngeal adductor reflex and the other with normal sensitivity. Subjects were given liquid and puree consistencies and were evaluated for aspiration as well as pharyngeal muscle contraction. RESULTS: The differences in incidence of aspiration and pharyngeal muscular weakness between the 2 groups were significant (P < 0.001 Fisher's exact test). CONCLUSION: There is a strong association between motor function deficits and hypopharyngeal sensory deficits. SIGNIFICANCE: The association of sensory loss and motor deficits together with the use of flexible endoscopic evaluation of swallowing with sensory testing can predict those patients who are at highest risk for aspiration