RESUMEN
OBJECTIVES: To quantify the safety and efficiency of Postgraduate-Year II head-and-neck-surgery residents who perform endoscopic sinus surgery, to observe any changes that accompanied accrued experience, and to measure and correlate blood loss and temporal efficiency with anesthesia-induced relative hypotension. DESIGN: Retrospective study. SETTING: University of California, San Diego, Medical Center. PATIENTS: One hundred two patients with chronic rhinosinusitis operated on between July 1, 2005, and June 30, 2006, by 3 Postgraduate-Year II head-and-neck-surgery residents. INTERVENTION: Endoscopic sinus surgery. MAIN OUTCOME MEASURES: Operative times, blood loss, case complexity, and anesthetic components were recorded and analyzed. RESULTS: One hundred two patients with chronic rhinosinusitis with and without polyposis received operative management. Mean operative time, with the inclusion of injection (10 minutes) and image guidance setup (5 minutes), was 77 minutes. Estimated blood loss averaged 42 mL for patients with chronic rhinosinusitis and 58 mL for patients with chronic rhinosinusitis and nasal polyps. The mean intraoperative blood pressure was 101/65 mm Hg. No major complications occurred. CONCLUSIONS: Endoscopic sinus surgery may be safely performed by Postgraduate-Year II head-and-neck-surgery residents by means of hypotensive anesthesia techniques and image guidance. Outcome analysis demonstrates minimal blood loss, efficient operative times, and no significant complications.
Asunto(s)
Competencia Clínica , Endoscopía/educación , Endoscopía/normas , Radiografía Intervencional , Rinitis/cirugía , Sinusitis/cirugía , Enfermedad Crónica , Femenino , Humanos , Hipotensión , Internado y Residencia , Masculino , Complicaciones Posoperatorias , Estudios Retrospectivos , Rinitis/diagnóstico por imagen , Sinusitis/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Adenoma/complicaciones , Neoplasias de las Paratiroides/complicaciones , Nervio Laríngeo Recurrente/patología , Parálisis de los Pliegues Vocales/etiología , Adenoma/diagnóstico , Adenoma/patología , Adenoma/cirugía , Anciano , Humanos , Laringoscopía , Masculino , Neoplasias de las Paratiroides/diagnóstico , Neoplasias de las Paratiroides/patología , Neoplasias de las Paratiroides/cirugía , Paratiroidectomía , Parálisis de los Pliegues Vocales/diagnósticoRESUMEN
HYPOTHESIS: Leukocyte recruitment to the cochlea can be induced by tumor necrosis factor alpha (TNF-alpha) at concentrations that are not cytotoxic to sensory cells in the organ of Corti. BACKGROUND: Leukocytes participating in inflammation enter the inner ear via the spiral modiolar vein and its tributaries. Many of the infiltrated leukocytes express TNF-alpha 3 hours after cochlear antigen challenge of systemically antigen-sensitized animals. Competitive inhibition of TNF-alpha receptors reduces inflammation and hearing loss in experimentally induced labyrinthitis in guinea pigs and mice. However, TNF-alpha is also potentially cytotoxic, acting through the external apoptotic pathway and TNF-alpha transmembrane, cell surface receptors. It may therefore also participate in the sensory cell degeneration resulting from inflammation. METHODS: To test for recruitment potential, TNF-alpha or phosphate-buffered saline was infused into the guinea pig inner ear for 2 to 4 days through a cochleostomy using an osmotic pump (0.2 or 2.0 microg/mL; 1 microL/h) or a bolus injection (50 microg/mL; 10 microL). Auditory evoked brainstem response thresholds were measured before and after challenge, and cochleas were evaluated for the presence of leukocytes. To test for toxicity, organ of Corti explants were subjected to 3 concentrations of TNF-alpha (0.1, 10, and 1,000 ng/mL) for 96 hours, and the number of hair cell places was counted. RESULTS: Tumor necrosis factor alpha infused into the guinea pig cochlear scala tympani resulted in infiltration of leukocytes around the venules and within scala tympani. There was no associated hearing loss as measured with a click stimulus. Tumor necrosis factor alpha applied directly to organ of Corti explants caused minimal hair cell death at concentrations used in the in vivo experiments. At higher concentrations, there was 15 to 20% loss of cells. CONCLUSION: Tumor necrosis factor alpha is sufficient to recruit inflammatory cells to the cochlea but is not likely to be directly responsible for the hearing loss that follows immune-mediated labyrinthitis.
Asunto(s)
Cóclea/efectos de los fármacos , Leucocitos/efectos de los fármacos , Factor de Necrosis Tumoral alfa/farmacología , Animales , Animales Recién Nacidos , Células Ciliadas Auditivas/efectos de los fármacos , RatonesRESUMEN
OBJECTIVES/HYPOTHESIS: This study used computed tomography (CT) to identify anatomic features of the awake upper respiratory tract (URT) that correlate with severity of obstructive sleep apnea (OSA). STUDY DESIGN: An IRB approved radiographic study of 80 patients with OSA and 56 patients from the general population. METHODS: Awake, noncontrast CT was performed from the skull base to the thoracic inlet in patients with OSA. Cross-sectional measurements of the retropalatal and retrolingual airways were made along with the size of the cervicomandibular ring and the percentage neck fat. The mandibular plane to hyoid distance, neck length, and laryngeal descent were also recorded. The posterior tongue fat content was estimated using the Hounsfield unit for radiodensity. The radiographic data were then compared with clinical information, including apnea-hypopnea index (AHI), body mass index, and neck circumference using linear regression. RESULTS: AHI increases with smaller retrolingual cross-sectional airway (P = .0026) and increasing mandibular plane to hyoid distance (P = .0003) but not retropalatal airway or laryngeal descent. The posterior tongue is hypodense with higher fat content than other muscles of the head and neck. CONCLUSIONS: This study describes anatomic findings of the retrolingual airway in patients that correlate with OSA and can be measured on an upper airway CT. Patients with severe OSA (AHI > or = 40) tend to have retrolingual airways less than 4% of the cross-sectional area of the cervicomandibular ring. The retrolingual airspace is the major site of obstruction in severe OSA and should be carefully evaluated before surgical treatment is considered.
Asunto(s)
Obstrucción de las Vías Aéreas/diagnóstico por imagen , Laringe/diagnóstico por imagen , Apnea Obstructiva del Sueño/diagnóstico por imagen , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuello/diagnóstico por imagen , Polisomnografía , Base del Cráneo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Lengua/diagnóstico por imagenRESUMEN
OBJECTIVES/HYPOTHESIS: Obesity as measured by body mass index (BMI) has been shown to correlate with incidence and severity of sleep disordered breathing (SDB), but the actual mechanism underlying this relationship has not been defined. Pharyngeal obstruction from posterior displacement of a large, fat laden tongue is one mechanism that may explain this link. The objective of this study is to characterize the fat content within the tongue and then to determine whether tongue weight and percent of fat correlate with BMI and other metrics of obesity. STUDY DESIGN: This is a cross-sectional anatomic study performed at autopsy in 121 consecutive medical examiner cases. METHODS: Tongues were harvested, weighed, and sectioned. A standardized photograph was taken of each tongue in the midsagittal plane. The image was imported into ImageJ (NIH) and then digitally analyzed to estimate fat distribution and percent within the tongue. The measurements were divided into age and sex subsets and then examined for correlation with height, weight, BMI, organ weight, and abdominal subcutaneous fat thickness. RESULTS: This study includes data from 88 males, 27 females, and 6 children. The average tongue weight for males was 99 g, range 71 to 143 g; for females, 79 g, range 51 to 135 g; and for children, (mean age 4 yr) 38 g, range 15 to 81 g. Tongue weight correlated with BMI (r = 0.6, P < .0001). Percent of fat in the posterior tongue averaged 30 +/- 12% and correlated with BMI (r = 0.5, P < .0001) for both men and women. Percent of fat in the anterior tongue averaged 10 +/- 5% and correlated with BMI for males (P < .001). Anterior tongue fat percent did not correlate with BMI in females. CONCLUSION: Increase in tongue weight and percentage of fat, and therefore tongue volume, may explain why patients with weight gain have higher rates of SDB. Tongue weight, fat, and volume may also correlate with and explain Mallampati grades.
Asunto(s)
Tejido Adiposo/patología , Obesidad/patología , Apnea Obstructiva del Sueño/patología , Lengua/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Autopsia , Índice de Masa Corporal , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Apnea Obstructiva del Sueño/etiologíaRESUMEN
OBJECTIVES/HYPOTHESIS: This study investigated the otoprotective properties of AM-111, an inhibitor of c-Jun N-terminal kinase-mediated apoptosis and inflammation. STUDY DESIGN: A controlled, prospective animal study using a guinea pig model of acute labyrinthitis. METHODS: Acute labyrinthitis was generated by injection of antigen into the scala tympani of sensitized guinea pigs. Treatment groups received 100 microL of AM-111 at concentrations of 100 micromol/L, 10 micromol/L, and 1 micromol/L in a hyaluronic acid gel formulation delivered over the round window niche within 1 hour of antigen challenge. Cochlear function was monitored over 21 days with serial auditory brainstem response (ABR) and distortion product otoacoustic emission (DPOAE) measurements followed by histologic analysis. RESULTS: The ABR results on day 21 demonstrated that untreated control ears for acute labyrinthitis had a mean hearing loss (HL) of 68 +/- 12 dB. In contrast, ears treated with AM-111 (100 micromol/L) had a mean HL of 39 +/- 31 dB. These two groups were statistically different (one-way analysis of variance, P = .03). Secondary outcomes, including DPOAE shift, inner hair cell survival, inflammatory cell counts, and spiral ganglion density, were also statistically significant in favor of an otoprotective effect of AM-111. Lower doses of AM-111 did not produce a statistically significant reduction in HL over controls. CONCLUSION: AM-111 delivered over the round window membrane in a 100 microL hyaluronic acid formulation at a 100 micromol/L concentration immediately after induction of acute labyrinthitis in the guinea pig cochlea protects hearing, reduces hair cell loss, and reduces the number of inflammatory cells at 21 days after treatment.
Asunto(s)
Pérdida Auditiva/prevención & control , Laberintitis/tratamiento farmacológico , Péptidos/uso terapéutico , Animales , Apoptosis/efectos de los fármacos , Recuento de Células , Modelos Animales de Enfermedad , Potenciales Evocados Auditivos del Tronco Encefálico/efectos de los fármacos , Femenino , Estudios de Seguimiento , Cobayas , Pérdida Auditiva/etiología , Pérdida Auditiva/fisiopatología , Laberintitis/complicaciones , Laberintitis/patología , Estudios Prospectivos , Ganglio Espiral de la Cóclea/efectos de los fármacos , Ganglio Espiral de la Cóclea/patología , Resultado del TratamientoRESUMEN
HYPOTHESIS: Cochlear microperfusion will be a useful treatment of severe sensorineural hearing loss caused by inflammation. BACKGROUND: Viruses, bacteria, and autoimmunity can initiate inflammation in the inner ear. The acute phase is associated with elevations in cytokines, nitrous oxide, and cellular infiltrates and the breakdown of the blood-labyrinthine barrier. The chronic phase leads to irreversible ossification of the labyrinth. METHODS: The authors developed cochlear microperfusion to facilitate removal of inflammatory cells and their byproducts during the acute phase of inflammation. Using a ventral approach to the guinea pig cochlea, the authors displaced resident perilymph by delivering perfusate into the scala vestibuli and collecting the effluent from the scala tympani. The authors evaluated the benefit of the procedure in an animal model of severe hearing loss caused by inflammation. RESULTS: Healthy controls undergoing cochlear microperfusion with phosphate-buffered saline incurred a mean hearing loss of 16 dB (n=4). This hearing loss was associated with the creation of two cochleostomies and not the perfusion itself. Sterile labyrinthitis (n=5) generated by perfusion of the cochlea with antigen consistently produced severe hearing loss over the initial 48 hours, and this hearing loss persisted for the subsequent 7 days. Therapeutic cochlear microperfusion, performed within the first 24 hours of developing severe hearing loss (n=9), immediately restored on average 24 dB (p <0.007) of hearing. CONCLUSION: Cochlear microperfusion is a promising new technique for treating severe deafness caused by inflammation. The benefit may be sustained when combined with local delivery of immunosuppressive agents to the inner ear.
Asunto(s)
Cóclea , Modelos Animales de Enfermedad , Pérdida Auditiva Sensorineural/terapia , Laberintitis/terapia , Perfusión/métodos , Animales , Umbral Auditivo/fisiología , Supervivencia Celular/fisiología , Cóclea/inmunología , Cóclea/patología , Femenino , Cobayas , Pérdida Auditiva Sensorineural/inmunología , Pérdida Auditiva Sensorineural/patología , Hemocianinas , Mediadores de Inflamación/metabolismo , Laberintitis/inmunología , Laberintitis/patología , Leucocitos , Fagocitos/inmunología , Rampa Timpánica/inmunología , Rampa Timpánica/patologíaRESUMEN
We report an unusual case of Merkel cell carcinoma presenting as a frontal scalp mass with apparent invasion into underlying brain parenchyma through grossly intact calvaria. Despite wide local excision, craniectomy, intracranial tumor resection, and postoperative adjuvant irradiation, widespread systemic metastases resistant to chemotherapy developed, and the patient died 9 months after surgery. This case report confirms that Merkel cell carcinoma of the head and neck, already known to be an aggressive tumor, has the capacity for rapid intracranial extension. We propose that in this case, the mechanism of intracranial metastasis was via communicating veins rather than through bone destruction or systemic metastasis. Appropriate preoperative imaging should be carried out to define the extent of this tumor when it is adjacent to the skull. We found contrast-enhanced magnetic resonance imaging to be superior to computed tomography for defining soft tissue extent and marrow space involvement within underlying bone.