Peritonsillar Abscess Outcomes with and Without Computed Tomography: A Retrospective Cohort Study.

OBJECTIVES: Peritonsillar abscess (PTA) is a common deep space head and neck infection, which can be diagnosed with or without computed tomography (CT). CT poses a risk for false positives, leading to unnecessary abscess drainage attempts without benefit, whereas needle or open aspiration without imaging could potentially lead to missed abscess in need of treatment. This study considered the utility and impact of obtaining CT scans in patients with suspected PTA by comparing outcomes between CT and non-CT usage. METHODS: Retrospective cohort analysis using TriNetX datasets compared the outcomes of two cohorts: PTA without CT and PTA with CT. Measured outcomes included incision and drainage; quinsy adenotonsillectomy; recurrent PTA; airway emergency/obstruction; repeat emergency department (ED) visits; and need for antibiotics, opiates, or steroids. Odds ratios (OR) were calculated using a cohort analysis. RESULTS: The CT usage group had increased odds of receiving antibiotics (OR 3.043, [2.043-4.531]), opiates (OR 1.614, [1.138-1.289]), and steroids (OR 1.373, [1.108-1.702]), as well as a higher likelihood of returning to the ED (OR 5.900, [3.534-9.849]) and developing a recurrent PTA (OR 1.943, [1.410-2.677]). No significant differences were observed in the incidence of incision and drainage, quinsy adenotonsillectomy, or airway emergency/obstruction. CONCLUSION: Our study indicated that CT scans for PTA diagnosis were associated with increased prescription of antibiotics, opioids, steroids, return ED visits, and recurrent PTA. Future prospective trials are needed to determine if the use of CT scans indicates higher patient acuity that explains the potential negative outcomes. LEVEL OF EVIDENCE: Level II Laryngoscope, 2024.

Squamous cell carcinoma of the temporal bone: a radiographic-pathologic correlation.

OBJECTIVE: To assess the utility of a previously proposed staging system for patients with primary squamous cell carcinoma of the temporal bone. METHODS: Retrospective chart review of 15 patients treated for squamous cell carcinoma of the temporal bone over a 13-year period at an academic tertiary referral center. A review of the medical and surgical records, radiographic studies, and surgical pathology reports allowed for an evaluation of the University of Pittsburgh staging system. Outcome analysis was performed on 13 patients with more than 24 months of follow-up. RESULTS: Radiographic and surgical pathology staging according to the University of Pittsburgh staging system correlated in 11 (73%) of 15 cases. The radiographic staging system was more accurate for larger (T3/T4) tumors than for smaller (T1/T2) tumors (83% vs 67%). When compared with patients with no evidence of disease, nonsurvivors were more likely to present with otalgia (67% vs 43%), facial nerve paralysis (33% vs 0%), and T3/T4 tumors (100% vs 14%). CONCLUSIONS: Pathologic staging by the University of Pittsburgh staging system closely correlates with patient outcome and is more sensitive than preoperative radiographic staging. Prognosis in squamous cell carcinoma of the temporal bone is largely determined by the extent of local disease at the time of presentation.

Role of middle turbinate biopsy in the diagnosis of fulminant invasive fungal rhinosinusitis.

OBJECTIVE: To determine the efficacy of middle turbinate biopsy in the diagnosis of fulminant invasive fungal rhinosinusitis. STUDY DESIGN: Nonrandomized prospective study. METHODS: Directed middle turbinate biopsy was performed in 25 patients suspected of having fulminant invasive fungal rhinosinusitis. All patients were immunocompromised and had fever of unknown origin, symptoms of rhinosinusitis, or both. RESULTS: Six patients were found to have fungal invasion on histopathological review (6 true-positive findings), disease developed in 2 patients with negative results on biopsy (2 false-negative findings), and disease never developed in 17 patients with negative results on biopsy (17 true-negative findings), resulting in an overall sensitivity of 75% and a specificity of 100%. CONCLUSIONS: Middle turbinate biopsy is a safe and effective method of making a timely diagnosis of fulminant invasive fungal rhinosinusitis. The added morbidity and cost of surgery can be avoided in the patient with a negative finding on biopsy. However, the effect of earlier diagnosis on overall patient survival is unclear at present.

The uvulopalatal flap for reconstruction of the soft palate.

OBJECTIVE: To determine the indications, complications, and outcomes of the uvulopalatal flap in the reconstruction of defects of the soft palate. STUDY DESIGN: Retrospective review. METHODS: Patient data were obtained from the hospital records of 18 patients who had soft palate defects reconstructed with the uvulopalatal flap over a 5-year period at a tertiary academic medical center. RESULTS: Eleven patients had the uvulopalatal flap as the sole method of reconstruction, whereas this flap was used in combination with a radial forearm free flap, pectoralis flap, and skin graft in 4, 2, and 1 patients, respectively. All flaps were successful in soft palate reconstruction. One flap was successfully revised after additional tumor resection. A partial flap dehiscence occurred in one patient and healed uneventfully. Speech and swallowing function was dependent on initial tumor stage and the scope of tumor resection. CONCLUSIONS: The uvulopalatal flap is a simple and effective method of soft palate reconstruction either alone or in combination with other methods of reconstruction for selected oropharyngeal defects.

An algorithmic approach to the diagnosis and management of invasive fungal rhinosinusitis in the immunocompromised patient.

Acute invasive fungal rhinosinusitis is a difficult disorder to diagnose and treat. A systematic approach to the susceptible patient, however, leads to an earlier diagnosis with improved survival. Early evaluation with rigid nasal endoscopy with frozen section biopsy of suspicious lesions or the middle turbinate should be considered in the high-risk population. Complete surgical resection and the reversal of neutropenia appear to be critical elements in achieving a successful outcome in patients with invasive fungal rhinosinusitis.

Outcomes of emergency surgical airway procedures in a hospital-wide setting.

OBJECTIVE: To review the circumstances, complications, and outcomes of emergency surgical airway procedures and to compare the relative merits of cricothyroidotomy and tracheotomy for airway control in a hospital-wide patient population. STUDY DESIGN: Retrospective review. METHODS: Patient data were obtained from the inpatient charts and electronic patient records of 35 patients who required an emergency surgical airway over a 6-year period at an urban medical center. RESULTS: Emergency cricothyroidotomy and tracheotomy were successfully performed in 34 of 35 patients (97%). Orotracheal intubation was successfully achieved in one patient with a failed cricothyroidotomy. The overall complication rates for emergency cricothyroidotomy and tracheotomy were similar (20% and 21%, respectively). Inpatients requiring an emergency surgical airway had a higher complication rate (32% vs. 0%) but better overall survival (91% vs. 46%) than patients treated in the emergency department. No long-term complications were observed from emergency cricothyroidotomies that were not converted to tracheotomies. CONCLUSION: The establishment of an emergency surgical airway by either tracheotomy or cricothyroidotomy is effective with low overall morbidity. The need to convert every emergency cricothyroidotomy to a tracheotomy should be reevaluated.

Glycine immunoreactivity of multipolar neurons in the ventral cochlear nucleus which project to the dorsal cochlear nucleus.

Certain distinct populations of neurons in the dorsal cochlear nucleus are inhibited by a neural source that is responsive to a wide range of acoustic frequencies. In this study, we examined the glycine immunoreactivity of two types of ventral cochlear nucleus neurons (planar and radiate) in the rat which project to the dorsal cochlear nucleus (DCN) and thus, might be responsible for this inhibition. Previously, we proposed that planar neurons provided a tonotopic and narrowly tuned input to the DCN, whereas radiate neurons provided a broadly tuned input and thus, were strong candidates as the source of broadband inhibition (Doucet and Ryugo [1997] J. Comp. Neurol. 385:245-264). We tested this idea by combining retrograde labeling and glycine immunohistochemical protocols. Planar and radiate neurons were first retrogradely labeled by injecting biotinylated dextran amine into a restricted region of the dorsal cochlear nucleus. The labeled cells were visualized using streptavidin conjugated to indocarbocyanine (Cy3), a fluorescent marker. Sections that contained planar or radiate neurons were then processed for glycine immunocytochemistry using diaminobenzidine as the chromogen. Immunostaining of planar neurons was light, comparable to that of excitatory neurons (pyramidal neurons in the DCN), whereas immunostaining of radiate neurons was dark, comparable to that of glycinergic neurons (cartwheel cells in the dorsal cochlear nucleus and principal cells in the medial nucleus of the trapezoid body). These results are consistent with the hypothesis that radiate neurons in the ventral cochlear nucleus subserve the wideband inhibition observed in the dorsal cochlear nucleus.

Prognosis in bilateral vestibular hypofunction.

OBJECTIVES/HYPOTHESES: The outcomes of patients with bilateral vestibular hypofunction vary widely. Some resume relatively normal activity within months, whereas others have a more debilitated course. This study sought to identify factors that may affect outcome. STUDY DESIGN: A retrospective review of patients treated for bilateral vestibular hypofunction over a 2-year period at a neurotology clinic. METHODS: Patients' medical charts, electronystagmography data, rotatory chair testing, and posturography results were reviewed. Subjective and objective measures were used to evaluate outcome. RESULTS: Bilateral vestibular hypofunction was diagnosed in 35 patients. Improvement after vestibular rehabilitation therapy was noted in 18 patients (51%), whereas 12 (34%) showed little or no change and 5 (15%) were not available for follow-up. The patients without improvement were more likely to have a chronic disorder as a cause of the vestibulopathy and had more medical comorbidities, on average, when compared with those who improved. Lower gains and time constants on rotatory chair testing were also seen in the group that did not improve. CONCLUSIONS: Poor rehabilitation results may be attributable to increased severity of vestibular insult, progressive peripheral or central vestibular dysfunction, and multiple medical problems.

An approach to fulminant invasive fungal rhinosinusitis in the immunocompromised host.

OBJECTIVE: To examine the pathogenesis of fulminant invasive fungal rhinosinusitis to determine factors that may affect patient survival. METHODS: Retrospective chart review of 25 patients treated for invasive fungal rhinosinusitis over a 10-year period at an academic tertiary referral center. Evaluation of the medical and surgical records, radiographic studies, surgical pathology specimens, and culture results allowed for a multifactorial comparison between survivors and nonsurvivors. Survivors were patients who left the hospital with the invasive fungal disease stable or cured. RESULTS: Fungal invasion often occurs within the nasal cavity (92% of patients), most commonly at the middle turbinate (62% of patients receiving biopsy). Survivors had complete surgical resection more often than nonsurvivors (90% vs 0%), and were more likely to respond to granulocyte colony-stimulating factor than nonsurvivors (100% vs 0% of those treated). CONCLUSIONS: Rigid nasal endoscopy with frozen section biopsy of suspicious nasal lesions and high-incidence areas (ie, middle turbinate) allows for the timely diagnosis of invasive fungal rhinosinusitis. Survival improves if the disease is limited to the nasal or sinus cavities, which may represent an earlier stage of disease. Favorable prognostic signs include the ability to achieve a complete surgical resection and a positive response to granulocyte colony-stimulating factor in the neutropenic patient.

Effect of blood pressure changes on air flow dynamics in the upper airway of the decerebrate cat.

BACKGROUND: Previous studies suggest that upper airway neuromuscular activity can be affected by changes in blood pressure via a baroreceptor-mediated mechanism. It was hypothesized that increases in blood pressure would increase upper airway collapsibility predisposing to airway obstruction at a flow-limiting site in the hypopharynx. METHODS: To examine the effect of blood pressure on upper airway function, maximal inspiratory air flow was determined through the isolated feline upper airway before, during, and after intravenous infusion of phenylephrine (10-20 micrograms.kg-1.min) in six decerebrate, tracheotomized cats. Inspiratory flow, hypopharyngeal pressure, and pressure at the site of pharyngeal collapse were recorded as hypopharyngeal pressure was rapidly decreased to achieve inspiratory flow limitation in the isolated upper airway. Pressure-flow relationships were used to determine maximal inspiratory air flow and its mechanical determinants, the upper airway critical pressure (a measure of pharyngeal collapsibility), and the nasal resistance upstream to the site of flow limitation. RESULTS: An increased mean arterial blood pressure of 71 +/- 16 mmHg (mean +/- SD) was associated with significant decrease in maximal inspiratory air flow from 147 +/- 38 ml/s to 115 +/- 27 ml.sec-1 (P < 0.01). The decrease in maximal inspiratory air flow was associated with an increase in upper airway critical pressure from -8.1 +/- 3.8 to -5.7 +/- 3.7 cm H2O (p < 0.02), with no significant change in nasal resistance. When blood pressure was decreased to baseline by discontinuing the phenylephrine infusion, maximal inspiratory air flow and upper airway critical pressure returned to their baseline values. CONCLUSIONS: Increased blood pressure increased the severity of upper airway air flow obstruction by increasing pharyngeal collapsibility. Previous studies relating baroreceptor activity to neuromuscular regulation of upper airway tone, are consistent with this effect being mediated by afferent activity from baroreceptors. These findings warrant further study because they suggest the possibility that upper airway obstruction in postoperative patients could either be caused or exacerbated by an increase in blood pressure.

Diagnosis and treatment of obstructive sleep apnea of the larynx.

To determine the mechanism for obstructive sleep apnea in two patients with clinical abnormalities of laryngeal function, airflow dynamics during sleep were analyzed. The site of airway obstruction was assessed by examining pressure gradients across specific airway segments. The relation between maximal inspiratory airflow and nasal pressure was analyzed to determine (1) the critical pressure, a measure of the collapsibility of the laryngeal airway, and (2) the effect of nasal continuous positive airway pressure on airflow during sleep. Large inspiratory pressure gradients developed during sleep between the supraglottic and pleural spaces, indicating that collapse had occurred in the larynx. Elevated critical pressures of -6.4 and +1.2 cm H2O, respectively, occurred in the two patients. When the nasal pressure was raised to 10 cm H2O, normal levels of tidal airflow occurred, and obstructive apneas were eliminated. These findings indicate that sleep apnea was caused by laryngeal airflow obstruction that resulted from elevations in the collapsibility of the larynx. The response to nasal continuous positive airway pressure suggested that laryngeal sleep apnea was similar to pharyngeal sleep apnea in pathophysiologic characteristic and response to treatment.

Starches of varied digestibilities differentially modify intestinal function in rats.

Starches of different digestibilities may enter the colon to different extents and alter colonic function. Male Fischer 344 rats were fed diets containing 25% cooked potato starch, arrowroot starch, high amylose cornstarch or raw potato starch for 6 wk. Fecal weight, transit time, colonic thymidine kinase activity (a marker for cell proliferation), and weight, starch content and pH of the cecum and proximal and distal colon were measured. Raw potato starch was much less completely digested than high amylose cornstarch, resulting in a 32-fold greater amount of undigested starch entering the cecum in the raw potato starch group. Both the high amylose cornstarch and raw potato starch diets significantly enhanced fecal weight and produced large intestinal hypertrophy, effects that were greatest in the raw potato starch group. Raw potato starch feeding was associated with the highest level of thymidine kinase activity, although the differences in thymidine kinase activity among the four groups were not significant. This diet also produced a 50% longer transit time. Entry of a large amount of raw potato starch into the colon resulted in greater luminal acidity, greater luminal bulk and slower transit. A much smaller amount of starch entered the colon in the high amylose cornstarch group and resulted in fecal bulking but no alteration in transit.

Suppression of estrogen-regulated extracellular tissue plasminogen activator activity of MCF-7 cells by 2,3,7,8-tetrachlorodibenzo-p-dioxin.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) suppresses the estrogen enhancement of tissue plasminogen activator (t-PA) by MCF-7 breast cancer cells. 17 beta-estradiol treatment of MCF-7 cells was previously shown to enhance t-PA secretion in a receptor-mediated process dependent on RNA and protein synthesis. The current studies demonstrate that treatment with TCDD, at a concentration as low as 10(-11) M, reduces the 17 beta-estradiol-induced enhancement of t-PA secretion in these cells. Treatment of MCF-7 cells with TCDD alone does not alter t-PA activity nor was inhibition of t-PA activity observed when TCDD was added directly to the enzyme assay. Kinetic studies and the lack of inhibition following in vitro mixing of conditioned media from TCDD-treated and control 17 beta-estradiol stimulated MCF-7 cells argue against TCDD induction of a plasminogen activator inhibitor. The related polychlorinated dibenzofuran, 2,3,7,8,-tetrachlorodibenzofuran, while also active, is less potent that TCDD. Other polychlorinated dibenzodioxins, polychlorinated dibenzofurans, and polychlorinated biphenyls do not suppress 17 beta-estradiol induction of t-PA over the concentrations tested. These results are in agreement with the structure-activity relationships established using these compounds in other assay systems. Treatment with TCDD does not alter the number or affinity of 17 beta-estradiol receptors of MCF-7 cells. TCDD treatment does not suppress constitutive t-PA activity in the estrogen independent breast cancer line MDA-MB-231 nor the t-PA induced by 12-O-tetradecanoylphorbol-13-acetate in HeLa cells. These effects suggest that TCDD is not acting directly on expression of the t-PA genome. Induction of aryl hydrocarbon hydroxylase by TCDD, a cytochrome P-450 regulated metabolic enzyme for which TCDD is the most potent known inducer, was observed in MCF-7 cells but not in MDA-MB-231 or HeLa cells. A plausible mechanism for the antiestrogenic activity of TCDD is based on the metabolic conversion of 17 beta-estradiol to less active derivatives by TCDD induced cytochrome P-450 metabolic enzymes.