Outpatient biopsies of the palatine tonsil: access to lymphoid tissue for assessment of human immunodeficiency virus RNA titers.

OBJECTIVES: Our objective was to assess the feasibility of using tonsillar lymphoid biopsy specimens obtained on an outpatient basis to quantitate a patient's lymphoid human immunodeficiency virus (HIV) RNA titers. DESIGN: A pilot cohort study was performed. PATIENTS: We evaluated ten HIV-seropositive patients who ranged in age from 26 to 48 years and had CD4+ cell counts ranging from 110 to 833 at enrollment. MAIN OUTCOME MEASURES: The main outcome measures were tolerance and safety of outpatient tonsil biopsies and quantitation of HIV RNA titers in tonsillar lymphoid biopsy specimens, plasma, and peripheral blood mononuclear cells determined by a new method of HIV RNA signal amplification with branched DNA probes. RESULTS: Outpatient tonsil biopsies were well tolerated and were performed without complications. Nine of 10 tonsil biopsies from the HIV-seropositive patients examined were positive for significant concentrations of HIV RNA, ranging from 106 to 101 HIV RNA equivalents per gram of tissue. All of the HIV RNA-positive tonsillar lymphoid specimens had HIV RNA titers that were 101 to 104 times greater than those recovered from plasma (per milliliter) of the same patient obtained at the time of biopsy. CONCLUSIONS: Sufficient tonsillar tissue can be obtained in an outpatient clinic setting to quantitate lymphoid HIV titers by the new branched-DNA signal amplification method with relative ease and without complication. The biopsy method described here affords ready access to the lymphoreticular system, which may help to advance our understanding of the pathogenesis of myriad immune diseases without the need for excisional node biopsies.

Frontal sinus fractures. Analysis of treatment results.

A retrospective study of 112 consecutive patients with frontal sinus fractures who were available for follow-up is presented. Significant complications are possible, especially with fracture of the posterior sinus wall. When indicated, the sinus is reconstructed with wire using free denuded fragments if available. Severe complications in displaced posterior wall fractures were less common when treatment was by sinus obliteration than by cranialization. Computed tomography has improved the evaluation, especially when a posterior wall fracture is suspected.

Venous hum as a cause of reversible factitious sensorineural hearing loss.

Self-heard venous hums have been previously documented and recognized as one cause of audible pulsatile tinnitus. A patient presented with a right internal jugular venous hum causing audible tinnitus and a right sensorineural hearing loss, both of which resolved after high ligation of the right internal jugular vein. We speculate that the hearing loss measured initially was factitious and represented a masking effect due to the venous hum.

Facial fractures in trauma victims: the influence of treatment delay on ultimate outcome.

To obtain objective data on the consequences of delayed treatment of facial fractures we reviewed the records of 220 patients who had suffered facial fractures concomitantly with extrafacial trauma severe enough in its own right to warrant hospital admission. Fractures studied were those of the mandible, maxilla, zygoma, and frontal sinus. Seventy-three patients fit inclusion criteria. Most injuries occurred in motor vehicle accidents. Associated extrafacial injuries were common and frequently multiple, the more serious of which generally took priority over the facial injuries in the triage system. The two most common reasons for delay were instability of the patient's neurological status, or initial non-recognition or poor definition of the facial fracture. Delays in treatment ranged from 0 to 24 days. In patients with mandible fracture only, delay of up to 24 days in definitive treatment led to no noticeable increase in morbidity due to malocclusion, infection, or nonunion. In no other facial fracture did treatment delay lead to an increased incidence of complications. Retrospective analysis of the patients who did suffer complications almost always revealed predisposing conditions that placed these patients at higher risk for poor results.

Chronic osteomyelitis following mandibular fractures and its treatment.

In a review of 350 patients with mandibular fractures between 1976 and 1978, eight cases of chronic mandibular osteomyelitis were found. Treatment in all cases consisted of intravenous antibiotics and debridement. In addition, in some cases a suction-irrigation system was used after debridement. From this study, the following can be stated: (1) Osteomyelitis following mandibular fractures is uncommon. (2) Once chronic osteomyelitis has developed, aggressive antibiotic and surgical treatment is needed. (3) The use of the suction-irrigation system after debridement is an effective adjunctive aid in treating osteomyelitis. Cosmesis is superior to that obtained with older techniques because wounds are closed primarily.

Treatment of maxillary cysts.

Differing classification systems for cysts of the maxilla have resulted in confusion in the literature regarding these cysts. We feel that proper evaluation and treatment is essentially the same regardless of the classificatory system employed. The hallmark of proper treatment of these cysts is meticulous removal of all cyst lining to prevent recurrence. Three case reports are presented and discussed.

Paper patch repair of blast rupture of the tympanic membrane.

An hotel explosion provided a need to treat five blast ruptured tympanic membranes in four firemen. Treatment consisted of early debridement and eversion of tympanic membrane flaps, Gelfoam to support these flaps and the placement of a paper patch for immediate closure of the drumhead defect and to provide a plane for epithelial growth. Pre and postsurgical audiometry demonstrate the immediate rehabilitation of conductive hearing in these patients. In all cases, immediate improvement in symptoms of aural fullness occurred. Tympanic membrane defects healed with minimal scarring in each case. Early debridement and paper patch repair are recommended for blast-ruptured tympanic membranes.

Delayed meningitis following stapes surgery.

Perilymphatic fistulae, developing even years after stapedectomy, open a communication between the perilymph and middle ear. These fistulae constitute a potential pathway for flora of the middle ear to invade the subarachnoid space by way of the cochlear aqueduct. Our patient developed pneumococcal meningitis 14 months after stapedectomy. The history of stapedectomy in a patient with meningitis is an indication for reexploration+ion of the operative site. The appearance of fistula symptoms in patients who have had stapedectomy indicates a high risk for development of intracranial infection.

Stabilization of comminuted zygomatic fractures with external suspension apparatus.

An external fixation device using a suspension bar fashioned from dental compounds is described. The finished appliance resembles a drawer pull from which the fractured malar eminence is suspended. The apparatus is recommended for the treatment of comminuted, unstable zygomatic fractures where conventional means of stabilization have proved unsatisfactory or undesirable and where passive traction is desirable. Appliances fashioned from lightweight dental compounds offer the maxillofacial surgeon a safe, effective, and highly versatile means of stabilizing facial fractures.

Nonunion of the mandible.

Nonunion of the mandible was evaluated over a five-year period (1968-1973). Fourteen cases were noted out of 577 mandibular fractures for an incidence of 2.4 percent. Causes of the complications were determined by a careful review of the poorly healing and successfully treated cases of mandibular fracture. The most important feature in nonunion cases was the large proportion of edentulous patients. In these cases immobilization appeared difficult, especially when only one form of fixation was used to stabilize the fracture. Other suspected causes of nonunion were postoperative trauma and osteomyelitis. These factors were most prevalent in the lower socio-economic groups. Factors which did not appear important were sex, age and cause of the fracture. Analysis of the site of injury, combinations of sites, timing of treatment, periosteal stripping and general health of the patient failed to demonstrate any predisposition to the complication. Treatment of nonunion was confined to standard techniques of debridement, antibiotic therapy and further immobilization. Although most patients responded to this therapy, six patients required closure of the deficit by bone grafting. On the basis of accumulated data, it was possible to clarify the factors in the development of nonunion. It was also possible to recommend methods of prevention of the complication and to substantiate the success of several forms of therapy.

The emergency management of trauma.

For effective care, the severely injured patient may require the cooperative effort of many physicians and paramedical personnel. In the individual with isolated maxillofacial injury, adequate management may be provided by one or several specialists. In any event, there should be a plan for emergency, semiurgent, and delayed treatment. It is also important for each individual caring for the patient to understand and appreciate the problems within and outside his area of expertise. There is a logical progression of evaluation, with particular attention to the more severe and significant area of trauma. Hemmorrhage, shock, and airway problems take priority. Often the definitive treatment, from a cosmetic and functional standpoint, is delayed.