Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery.

PURPOSE: We compare estimated blood loss (EBL) during endoscopic sinus surgery (ESS) between patients receiving transoral greater palatine canal (GPC) and transnasal infiltration (combined group) to patients receiving only transnasal infiltration (control group). CT stage, endoscopic stage, revision surgery, presence of polyps, degree of resident involvement, and operative time (OT) are also evaluated. METHODS: Injection with 1% lidocaine with 1:100,000 epinephrine was performed through the GPC and transnasally in the "combined" study group (20 patients) and only transnasally in the control group (22 patients). Charts, operative reports, and CT scans were reviewed and demographic data as well as pertinent information collected. Data analysis was performed using SPSS Version 16 (SPSS Inc., Chicago, Illinois). RESULTS: Twelve females and 8 males underwent combined injections and 16 males and 6 females received transnasal injections only. Average ratio of EBL to OT was 2.9 mL/min for the combined group and 4.1 mL/min for the control group (p=0.05). Presence of polyps and revision surgery lead to a statistically significantly higher EBL (p<0.05). Increased EBL and OT were noted with higher endoscopic and CT stages. No complications were reported. CONCLUSIONS: Increased endoscopic and CT stages, presence of polyps, and revision surgery may all lead to greater EBL in ESS. Although there was a trend towards decreased EBL in the combined group, this however did not reach statistical significance. Combined injection through the GPC and nasal cavity appears to be a safe method to decrease EBL during ESS.

Psychological considerations in the revision rhinoplasty patient.

The nose contributes greatly to the facial aesthetic. Derangements in nasal cosmesis, whether from surgery, trauma, or natural causes, have a plethora of implications for the emotional well-being of the individual. Rhinoplasty and revision rhinoplasty are both facial cosmetic operations that have potentially profound cosmetic, and therefore psychological, implications for the patient. Although many revision rhinoplasty patients have hopeful yet realistic surgical expectations, there is a subset of revision rhinoplasty patients having underlying psychological disturbances that may negatively affect the surgical outcome, no matter how favorable the surgical improvement. In this article, the various psychological disorders impacting revision rhinoplasty patients will be discussed. In addition, this article will familiarize the revision rhinoplasty surgeon with many of the hallmark characteristics of psychopathology, as well as the typical emotional presentation of the well-adjusted revision rhinoplasty patient, to facilitate differentiation between these seemingly similar, but distinctly different patient groups.

Common technical causes of the failed rhinoplasty.

The adverse rhinoplasty outcome may result from a wide variety of dissimilar causes. Although these causes include psychiatric patient disturbances and severely aberrant wound-healing responses, by far the most common etiology of the failed rhinoplasty is technical failure on behalf of the surgeon. Moreover, a disproportionate number of technical shortcomings stem from errors in basic rhinoplasty technique. Hence, mastery of rhinoplasty fundamentals will prevent a large number of novice errors that often taint the cosmetic outcome. Because many of the remaining technical errors stem from overaggressive tissue removal, tissue-sparing rhinoplasty techniques will also prevent many common causes of technical failure. This article identifies some of the more common technical errors associated with the unsuccessful cosmetic rhinoplasty and also provides insights as to their avoidance.

Endoscopic embolization with onyx prior to resection of JNA: a new approach.

OBJECTIVE: To report a novel pioneering approach of endoscopic embolization (EE) and resection of juvenile nasopharyngeal angiofibroma (JNA) and describe all outcomes and results. METHODS: Four patients presented to the University of Miami with repeated episodes of unilateral epistaxis diagnosed by fiberoptic and radiographic examination as nasal JNA. Subsequently, in conjunction with neurosurgery, endoscopic visualization was provided to perform intratumor needle insertion, through which the liquid embolic agent Onyx was infused to embolize the JNA's under fluoroscopic and endoscopic guidance. The day after EE, endoscopic resection was performed. Operating room time, estimated blood loss (EBL), and other intraoperative and post-operative results are reported and compared to published literature. RESULTS: A total of 4 patients (all males), had EE of JNA and subsequent endoscopic resection between September 2008 and January 2009. Average EBL during surgery was 412.5 ml (range 150-800) with an average operating room time of 228 min (range 95-485). We experienced no bleeding from the tumor or its attachments, only from the approach. Two patients experienced mild numbness in the V2 distribution, which began to resolve one week post-operatively. No other complications were encountered. CONCLUSIONS: This is the first published report of direct endoscopic embolization of JNA with Onyx. Although further studies are needed, it seems to provide a safe, less invasive alternative to traditional embolization and endoscopic resection, but must be done in cooperation with interventional neurosurgery to maximize its safety profile.

Outcomes of laser thermal therapy for recurrent head and neck cancer.

OBJECTIVE: To review the outcomes of a phase II study using laser-induced thermal therapy (LITT) as a palliative treatment for 106 patients with recurrent head and neck tumors. STUDY DESIGN: Retrospective study. SETTING: Tertiary hospital in the United States. SUBJECTS AND METHODS: The primary endpoints were tumor response and survival. Prognostic values were assessed by the Kaplan-Meier method. RESULTS: The best results were seen in oral cavity tumors, in which mean survival was 29.1 months, as compared to neck tumors (mean 14.4 +/- 6.9 months; range 7.5-20.7 months; with a 95% confidence interval). Further analysis showed that clinical factors such as gender, smoking, and alcohol use were not indicators of poor prognosis, whereas neck disease and tumor stage at first treatment were relevant factors. CONCLUSION: In this study, 40 out of 106 patients treated by LITT remained alive at the end of our follow-up, and a complete response was seen in 24 (22.6%) patients. The highest response rate was seen in oral cavity tumors, which suggests that tumor location at this site may be a predictor of favorable outcome with LITT.

Endoscopic endonasal resection of esthesioneuroblastoma: a multicenter study.

BACKGROUND: This study reports the combined experience of the University of Miami and University of Pittsburgh with endoscopic endonasal resection of esthesioneuroblastoma (ENB). A retrospective case series review was performed in a tertiary care university hospital. METHODS: Twenty-three patients, 16 men and 7 women, were reviewed. Mean age was 56.6 years (15-79 years). Nineteen patients received primary endoscopic endonasal anterior skull base resection. Of these, the modified Kadish stage at presentation was A in 2 patients, B in 11 patients, C in 5 patients, and D in 1 patient. Three patients had revision surgeries for recurrent tumors. The main outcome measures were complete resection and margin assessment, short-term and long-term complications, and recurrence rate. RESULTS: Complete resection and negative intraoperative resection margins were achieved endoscopically in 17 of the primarily treated cases. The two other cases had one patient that required an additional craniotomy approach to complete the resection of a positive lateral dual margin, another patient had positive margins at the orbital apex. All patients tolerated the endoscopic procedure very well with no meningitis. There were four cerebral spinal fluid leaks. Mean follow-up period for the primarily treated cases was 45.2 months (11-152 months), all were disease free at the most recent available follow-up. CONCLUSION: In experienced hands and carefully selected patients, endoscopic resection of ENB respects the principles of oncologic surgery, providing an adequate exposure for margin assessment as well as reliable reconstruction of the anterior skull defect with a relatively low morbidity.

Retention of intratumor injections of cisplatinum in murine tumors and the impact on laser thermal therapy for cancer treatment.

Recent studies using murine models of human squamous cell carcinoma (SCCA) have revealed a significant improvement in survival and cure rate of animals transplanted with human SCCA when treated with a combination of intratumor injections of chemotherapy and laser induced thermal therapy (LITT). These preliminary results suggest that this novel combination therapy may lead to improved clinical response compared to either treatment modality alone. Using a murine model of human SCCA we investigated two different modes of intratumor injection of cisplatin: a sustained-release cisplatin gel implant (CDDP/gel) versus cisplatin in solution (CDDP) at varying doses (range 1-3 mg/ml). In addition, we tested CDDP/gel combined with LITT. Results showed optimal drug concentration (30-300 nM) at tumor margins up to 4 h after injection of CDDP/gel implant compared to 3 nM at 5 min after injection with CDDP solution. Combined CDDP/gel and laser therapy significantly decreased tumor volume (P<0.05), with recurrence in only 25% of animals tested, compared to 78% tumor regrowth after LITT alone. These results suggest that laser chemotherapy may be an effective treatment for head and neck SCCA.

Blocking c-Jun-N-terminal kinase signaling can prevent hearing loss induced by both electrode insertion trauma and neomycin ototoxicity.

Neomycin ototoxicity and electrode insertion trauma both involve activation of the mitogen activated protein kinase (MAPK)/c-Jun-N-terminal kinase (JNK) cell death signal cascade. This article discusses mechanisms of cell death on a cell biology level (e.g. necrosis and apoptosis) and proposes the blocking of JNK signaling as a therapeutic approach for preventing the development of a permanent hearing loss that can be initiated by either neomycin ototoxicity or electrode insertion trauma. Blocking of JNK molecules incorporates the use of a peptide inhibitor (i.e. D-JNKI-1), which is specific for all three isoforms of JNK and has been demonstrated to prevent loss of hearing following either electrode insertion trauma or loss of both hearing and hair cells following exposure to an ototoxic level of neomycin. We present previously unpublished results that control for the effect of perfusate washout of aminoglycoside antibiotic by perfusion of the scala tympani with an inactive form of D-JNKI-1 peptide, i.e. JNKI-1(mut) peptide, which was not presented in the original J. Neurosci. article that tested locally delivered D-JNKI-1 peptide against both noise- and neomycin-induced hearing loss (i.e. Wang, J., Van De Water, T.R., Bonny, C., de Ribaupierre, F., Puel, J.L., Zine, A. 2003a. A peptide inhibitor of c-Jun N-terminal kinase protects against both aminoglycoside and acoustic trauma-induced auditory hair cell death and hearing loss. J. Neurosci. 23, 8596-8607). D-JNKI-1 is a cell permeable peptide that blocks JNK signaling at the level of the three JNK molecular isoforms, which when blocked prevents the increases in hearing thresholds and the loss of auditory hair cells. This unique therapeutic approach may have clinical application for preventing: (1) hearing loss caused by neomycin ototoxicity; and (2) the progressive component of electrode insertion trauma-induced hearing loss.

Ultrasound-guided laser-induced thermal therapy of malignant cervical adenopathy.

OBJECTIVES: Laser-induced thermal therapy (LITT) for cancer is a technique whereby a source of energy (laser, radiofrequency, ultrasonic, cryoenergy, and so on) is directly applied into a tumor at various depths. Recent studies have demonstrated the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real- or "near" real-time tumor and vessel identification as well as monitoring and quantifying energy-induced tissue damage. The objective of this study is to report UCLA's experience using UTZ monitoring of Nd:YAG laser thermal ablation of malignant cervical adenopathy in a phase II study. STUDY DESIGN: The authors conducted a retrospective study of patients treated at a tertiary medical center. METHODS: Forty-seven patients with a total of 55 neck tumors were treated on an outpatient basis in the operating room using UTZ for image-guided laser interstitial thermal therapy. Laser energy was delivered through an SLT Nd:YAG laser powered at 30 W (power density: 2,200 J/cm). RESULTS: Eleven patients had a complete response ranging from 5.5 to 90 months (mean, 22.1 months). Based on the findings of this study, it was possible to show that proximity to the carotid artery was the most relevant factor in projecting patient survival. Patients' individual treatment analysis and final outcome are further discussed. CONCLUSIONS: LITT ablation of malignant cervical adenopathy was considered safe and feasible. No intraoperative complications occurred. Further development of this technique applying laser energy delivery to mathematical imaging models should lead to more effective tumor palliation as an alternative to surgery.

Hypericin and pulsed laser therapy of squamous cell cancer in vitro.

OBJECTIVE: This in vitro study compares continuous wave and pulsed laser light at longer wavelengths for activation of the phototoxic drug hypericin in human cancer cells. BACKGROUND DATA: Two-photon pulsed laser light now allows high-resolution fluorescent imaging of cancer cells and should provide deeper tissue penetration with near infrared light for improved detection as well as phototoxicity in human tumors. METHODS: Cultured Seoul National University (SNU)-1 tumor cells from a squamous cell carcinoma (SCC) were incubated with hypericin before photoirradiation at four laser wavelengths. Phototoxicity of hypericin sensitized SCC cells was measured by dimethyl thiazoldiphenyl (MTT) tetrazolium bromide cell viability assays and by confocal fluorescence microscopy via 532-nm and infrared two-photon pulsed laser light. RESULTS: Phototoxic response increased linearly with hypericin dose of 0.1-2 microM, light exposure time of 5-120 sec, and pulsed dye laser wavelengths of 514-593 nm. Light energy delivery for 50% cell phototoxicity (LD50) response was 9 joules at 514 nm, 3 joules at 550 nm, and less than 1 joule at the 593 nm hypericin light absorption maxima. Fluorescence confocal microscopy revealed membrane and perinuclear localization of hypericin in the SNU cells with membrane damage seen after excitation with visible 532 nm continuous wave light or two-photon 700-950 nm picosecond pulsed laser irradiation. CONCLUSIONS: Hypericin may be a powerful tumor targetting drug when combined with pulsed laser light in patients with recurrent head and neck SCC.

Intratumor injections of cisplatin and laser thermal therapy for palliative treatment of recurrent cancer.

OBJECTIVE: The aim of this work was to report initial findings on the clinical application of intratumor injection of cisplatin in a gel (CDDP/gel) combined with laser-induced thermal therapy (LITT) for cancer treatment in a single patient with advanced stage disease. BACKGROUND DATA: LITT with the neodymium:yttriumaluminum- garnet (Nd:YAG) laser via fiberoptics is a precise, minimally invasive alternative for thermoablation of unresectable or recurrent head and neck neoplasms, but recurrence is often seen at the treatment margins. Combining intratumor chemotherapy with interstitial laser should be most effective using drugs with thermally enhanced toxicity, such as cisplatin. The CDDP/gel therapeutic implant was expected to retain a higher concentration of cisplatin in the tumor margins for improved LITT treatment of the patient presented. METHODS: In this case report, the cisplatin dose was 0.25 mL gel/cm(3) tumor volume (20 mg of CDDP) followed by LITT (Nd:YAG laser, 50 W, PD = 2,200 J/cm(2)) after the chemotherapy session. RESULTS: The patient responded with local tumor eradication, and no signs of systemic toxicity were observed related to this therapy. However, the patient developed progressive metastatic disease in the lungs and died 2.5 months later. CONCLUSIONS: This is a report of a patient with an accessible solid tumor who was treated with intratumor injection of CDDP/gel followed by LITT, which proved to be feasible. Based on preclinical evidence obtained at UCLA and the results of this study, we are encouraged to continue our refinement of LITT combined with chemotherapy for cancer treatment.

Occupational issues in episodic care populations.

BACKGROUND: Much care for non-emergency problems is provided at "episodic care" settings (e.g., urgent care and emergency room). METHODS: Ninety-four subjects, without known occupational disease, who were seeking care for a chronic or sub-acute problem in an episodic care location, were interviewed to assess the frequency and types of occupational health concerns. They were asked whether work probably "caused" or "made worse" their illness and whether their illness "made work difficult." RESULTS: Categorized hierarchically, 20% reported causation, 15% worsening, and 15% interference of illness with work. (Each was categorized in one category only). Only 50% reported absence of a workplace-health interaction. One-third reported that workplace changes could improve their functional status. Nevertheless, workplace factors were discussed only 21% of the time in physician-patient encounters. CONCLUSIONS: This study suggests that occupational health issues are frequent in episodic care settings and that the definition of occupational health issues should be broadened to include "made worse" and "illness makes work difficult" as well as the traditional workplace causation definition. Further, episodic care settings present unique opportunities for prevention.

Nd:YAG laser therapy for palliation of recurrent squamous cell carcinomas in the oral cavity.

BACKGROUND AND OBJECTIVES: The objective of this study was to evaluate the outcome of laser photo-thermoablation for palliation of recurrent squamous cell tumors of the oral cavity. STUDY DESIGN/PATIENTS AND METHODS: Seventeen patients were treated with the Nd:YAG laser (power output was 50 W) delivered through a curved oral handpiece. RESULTS: Ten patients are alive, 7 with tumor remission, and 3 with persistent disease with an average follow-up of 16 months (range = 2-36). A total of 29 tumor sites received laser treatment with 17 (58%) completely ablated. Stratified by tumor site Nd:YAG treatment led to complete local response in 8/10 buccal mucosa, 2/5 retromolar trigone, 2/2 tongue, 2/5 gingiva, 1/2 floor of mouth, 2/4 hard palate. CONCLUSIONS: Nd:YAG laser treatment of recurrent oral cavity squamous cell carcinoma can be performed safely and repeated as needed to achieve tumor palliation. However, extended follow-up may be needed before convincing evidence of long-term therapeutic benefits is obtained.