Efficacy of preoperative dual-phase sestamibi scanning in hyperparathyroidism.

PURPOSE: The objective of this article is to evaluate our experience with sestamibi scanning in patients with primary and secondary hyperparathyroidism. PATIENTS AND METHODS: A retrospective review of patients referred to the radiology department at the University of Kansas Medical Center for parathyroid studies between January 1, 1993, and August 1, 1998, was done. Patients included in the study were those who underwent both dual-phase technetium (Tc-99m) sestamibi scanning and subsequent parathyroidectomy at our institution (n = 34). Twenty-six patients had primary hyperparathyroidism and 8 patients had secondary hyperparathyroidism. Fifteen had previous history of neck exploration. RESULTS: Sensitivity of sestamibi scans in detection of all abnormal pathology in cases of primary hyperparathyroidism was 60% overall. Among the subset of adenoma cases, sensitivity was 82% (14/17). Among cases of primary parathyroid hyperplasia, no scan correctly localized all abnormal glands; however 60% (3/5) showed localization of at least one hyperplastic gland. Of the 2 patients with parathyroid carcinoma, in only one case was there evidence of sestamibi retention in the correct thyroid lobe. In patients with secondary hyperparathyroidism, sestamibi scanning was successful in identifying all hyperplastic tissue in only one case (sensitivity 13%). In 7 of the 8 cases of secondary hyperparathyroidism, the scan localized at least one hyperplastic gland. CONCLUSION: Sestamibi scanning is useful in the localization of abnormal pathology in cases of primary hyperparathyroidism, especially adenomas. In cases of hyperplasia, whether attributable to primary or secondary hyperparathyroidism, sestamibi imaging is less successful.

Characterization of cyclooxygenase in laryngeal papilloma by molecular techniques.

OBJECTIVES: Demonstrate the induction of cyclooxygenase-2 (COX-2) in laryngeal papilloma Discuss the possible causal role of COX-2 in papilloma formation. Consider the potential for treatment of papilloma using selective COX-2 inhibitors. STUDY DESIGN: Molecular biological analysis of COX-1 and COX-2 in laryngeal papilloma. METHODS: Tissue samples from five patients with recurrent respiratory papillomatosis (RRP) were analyzed by in situ hybridization, immunohistochemical staining, and reverse transcription polymerase chain reaction (RT-PCR) techniques. RESULTS: In situ hybridization to COX-2 mRNA showed strong autoradiographic signal surrounding fibrovascular cores. COX-1 autoradiographic signal was low intensity or nondetectable. Normal buccal mucosa biopsies showed low-density or nondetectable autoradiographic signal for both COX-1 and COX-2 mRNAs. In situ hybridization results were corroborated by RT-PCR studies. Levels of COX-2 mRNA were 13-fold more than those in normal mucosa. Immunohistochemical staining for COX-1 and COX-2 showed a similar pattern to that seen with in situ hybridization in both normal and papilloma tissues. CONCLUSIONS: There is an elevation of COX-2 expression in papilloma tissues. This may represent a causal role of COX-2 in the formation and proliferation of laryngeal papilloma. There may also be a role for selective COX-2 inhibition for the treatment of

Breed differences in deafferentation-induced neuronal cell death and shrinkage in chick cochlear nucleus.

Removal of functional presynaptic input can result in a variety of changes in postsynaptic neurons in the central nervous system, including altered metabolism, changes in neuronal cell size, and even death of the postsynaptic cell. Age-dependent neuronal cell death and shrinkage has been documented in second order auditory neurons in the chick brainstem (nucleus magnocellularis, NM) following cochlea removal (Born and Rubel, 1985. J. Comp. Neurol. 231, 435-445). Here we examined whether the extent of neuronal cell death and shrinkage is also breed-dependent. We performed unilateral cochlea removal on both hatchling and adult birds of either a broiler breed (Arbor Acres Cross) or egg layer breed (Hy-Line, H and N) and killed birds one week later. Changes in neuronal cell number and cross sectional area were determined from Nissl-stained sections. We observed 25% neuronal cell loss and a 15-20% decrease in neuronal cross sectional area after cochlea removal in either broiler or egg layer hatchling birds. In adult birds, however, neuronal cell loss is breed-dependent. Adult egg layer birds lose an average of 37% of NM neurons after cochlea removal, while adult broiler birds show no cell loss. In both breeds of adult birds, cochlea removal results in a 20% decrease in neuronal cross sectional area. These results suggest that analysis of differences between breeds as well as ages of birds will prove fruitful in determining how afferent input controls neuronal survival and metabolism.

Diagnosis and treatment of unilateral cricothyroid muscle paralysis with a modified Isshiki type 4 thyroplasty.

Cricothyroid adduction increases tension to the vocal folds, thus increasing fundamental frequency and upper pitch range. We treated 10 patients with cricothyroid muscle dysfunction using this technique. Preoperative electromyographic, acoustic, and perceptual analysis was performed. Intraoperatively the effect of increasing tension on the fundamental, falsetto, and basal frequencies was measured by using a strain gauge to the adducting suture at several tensions and a cervical microphone connected to a pitch meter. Postoperative acoustic and perceptual analysis was then performed up to 18 months later. Analysis of pitch vs. tension curves indicates a near-linear relationship until very high tensions are applied. Statistically significant improvement was achieved in both acoustic and perceptual analysis, although some deterioration was noted between early and late results. Cricothyroid adduction is indicated for a large range of vocal fold tension problems.

Surgical strategy in thyroid disease.

Over the past 8 years, 311 patients have undergone surgical treatment by the senior authors for thyroid disease. Over 80% of the cases were performed by the head and neck surgical service at Olive View County Hospital, Sylmar, Calif, with the remainder performed at UCLA-affiliated institutions. This service is an important source of thyroid surgical training for UCLA head and neck residents who rotate through this major affiliate. The purpose of this communication is to review our experience with these cases; to describe our overall surgical strategy; and to detail the specifics of our surgical procedure, which we have developed to safely train residents in the treatment of these challenging cases. This article deals with the specific problems of preservation of the recurrent nerve, the parathyroid glands, and the techniques for reimplantation of injured parathyroid glands; the management of larger, substernal thyroid glands; and our techniques for partial thyroid surgery. In addition, the difficult decisions in the management of thyroid cancer, such as completion thyroidectomy; the management of lymph node mestastases; and how tracheal, esophageal, or laryngeal invasion should be managed are discussed. An initial section describing the general preoperative examination of these patients is also included, so that the proper surgical strategy can be developed prior to entering the operating room.

Pharyngoesophageal intubation injuries: three case reports.

The hypopharynx and cervical esophagus are particularly vulnerable to intubation trauma. Contributing factors include hasty intubation by inexperienced personnel; the use of curved, beveled endotracheal tubes containing stylets; malpositioning of the head, and the application of cricoid pressure. Iatrogenic pharyngoesophageal perforations may go unsuspected until characteristic signs and symptoms are recognized. These include cervical pain, fever, dysphagia, leukocytosis, subcutaneous emphysema, and pneumomediastinum. We present three cases that illustrate important points in recognizing, evaluating, and treating pharyngoesophageal perforations. The third case presents a chronic cervical esophageal perforation with secondary pseudodiverticulum, requiring resection of the pseudodiverticulum and a primary sternocleidomastoid muscle flap repair of the cervical esophageal defect. To our knowledge, this technique has not previously been reported.

Parathyroid carcinoma: clinical presentation and treatment.

Parathyroid tumors account for only a small percentage of all head and neck neoplasms. The overwhelming majority of these are parathyroid adenomas that result in primary hyperparathyroidism. From 0.5% to 4% of hyperparathyroid patients, however, will be found to have a parathyroid carcinoma. In this paper, the authors relate their recent experience with such a patient and with two other such cases. Parathyroid carcinoma patients usually present with striking hyperparathyroidism and hypercalcemia, with the resultant related symptoms being more severe than those associated with parathyroid adenomas. Parathyroid carcinomas also tend to be large and may be detectable by current imaging techniques. The surgical appearance of these lesions is also distinct; the tumors are frequently multilobulated, gray-tan in color, quite firm, and often invasive. These physical findings are important since frozen section diagnosis may be difficult. The final histologic diagnosis depends on the presence of mitotic figures and capsular and vascular invasions. Preoperative medical problems, surgical approach, and prognostic factors are also discussed.

Congenital muscular torticollis. A spectrum of disease.

Sternocleidomastoid muscle fibrosis has been recognized for centuries, but its pathogenesis and treatment remains controversial. Pseudotumor of infancy is a firm fibrous mass in the sternocleidomastoid muscle appearing at 2 to 3 weeks of age. Congenital muscular torticollis is less common and appears later in life. Pseudotumor and congenital muscular torticollis probably represent different manifestations of sternocleidomastoid muscle fibrosis. Pseudotumor will usually resolve with conservative therapy; however, some patients will subsequently develop torticollis. Congenital muscular torticollis usually requires surgical release of the sternocleidomastoid muscle to achieve a good cosmetic result and to prevent plagiocephaly, facial asymmetry, and scoliosis. This report provides guidelines for the management of congenital muscular torticollis and pseudotumor of infancy based on the authors' experience and review of the medical literature. Representative case histories from the neonate through the adult are presented, and the pathogenesis, diagnosis, treatment, and prognosis are discussed.

Fine-needle aspiration diagnosis of extragonadal choriocarcinoma with immunoperoxidase studies.

A case of extragonadal choriocarcinoma in a 30-yr-old man was diagnosed by fine-needle aspiration (FNA) biopsy with immunoperoxidase studies. FNA diagnosis in this case resulted in prompt treatment of rapidly growing metastases without the need for an invasive diagnostic procedure.

Stabilization of hearing loss in Paget's disease with calcitonin and etidronate.

Paget's disease is a common skeletal disease characterized by abnormal bony resorption and deposition. Although the disease principally affects the axial skeleton, skull and temporal bone involvement occur. Affected individuals have significantly different rates of progression of hearing loss than normal persons. We describe two patients in whom this progressive hearing loss was halted and even reversed. These patients were treated with calcitonin and etidronate disodium and have been followed up for five and 3 1/2 years, respectively. Computed tomographic scans demonstrating extent of disease are included along with our treatment regimen and alkaline phosphatase response curves.

Autotransplantation of parathyroid tissue into sternocleidomastoid muscle.

Four cases of secondary hyperparathyroidism were treated by total parathyroidectomy with autotransplantation into the sternocleidomastoid muscle. These total parathyroidectomy patients are presented to demonstrate the reliability of parathyroid autotransplantation into the sternocleidomastoid muscle. Our technique is described in detail, and all procedures were successful. In one case, the patient was found, in retrospect, to have an adenoma in the transplanted parathyroid tissue. When the patient developed graft-dependent hypercalcemia, a portion of the graft was easily excised under local anesthesia and the patient became normocalcemic. Parathyroid tissue should be transplanted into the sternocleidomastoid muscle rather than other sites because of easy accessibility, one operative site, less graft ischemia, a low incidence of infection, and a high success rate due to excellent blood supply.

Physiologic exclusion of the injured esophagus.

Despite continuing advances in the surgical and nutritional management of esophageal perforation, morbidity and mortality remain significant. Described within is the successful management of two such cases by the physiologic exclusion of the esophagus. By this, we mean distal decompression and proximal diversion and decompression through a gastrostomy and cervical esophagostomy. This provides the greatest chance for protection of the esophageal suture line repair.

Prostatic adenocarcinoma metastatic to chronic subdural hematoma membranes. Case report.

A case of adenocarcinoma of the prostate metastatic to chronic subdural hematoma membranes is presented. The relevant literature is reviewed and the mechanism of transdural invasion by metastatic tumor cells is discussed.

Vertigo in the hyperviscosity syndrome.

Diseases that cause hyperviscosity of the blood can result in otologic symptoms--especially vertigo. These symptoms are predominantly produced by peripheral vestibular involvement. The pathophysiology probably involves vascular obstruction in the venules. Specific changes in the microvasculature are presumed to be comparable to those that occur with hyperviscosity disorders in the retina. Maintenance of a normal blood viscosity will prevent damage to the ear, as well as other organs. Additionally, reduction of the blood viscosity can greatly improve otologic symptoms. Case studies and a review of the pertinent literature are included.

Polyarteritis nodosa involving only the main renal arteries.

A unique case of accelerated hypertension and acute anuria in a 24-year-old man is presented. Clinically, the patient was found to have obstruction of both main renal arteries caused by extensive bilateral thrombosis. Microscopically, a healing panarteritis involving only the main renal arteries was found. This was associated with acute renal infarction and tubular atrophy in the left kidney. This appears to be an unusual variant of polyarteritis nodosa limited to both main renal arteries.

Traumatic innominate pseudoaneurysm rupture during laryngeal dilatation.

Endotracheal hemorrhage from the innominate artery is, fortunately, a rare problem encountered by the otolaryngologist. We present a patient with a tracheal-innominate artery fistula secondary to delayed rupture of a traumatic innominate artery aneurysm. The differential diagnosis of innominate artery hemorrhage is discussed, as is the management of this potentially lethal event. We propose, as the treatment of choice, cessation of hemorrhage through the use of a cuffed endotracheal tube, followed by ligation of the innominate artery using cardiopulmonary bypass. These techniques were used in this patient with a successful outcome.

Computed tomography of the submandibular salivary glands.

Computed tomography offers a convenient method for the evaluation of the submandibular salivary glands and their surroundings. Normal measurements were established based on 38 normal subjects. The visualization of the ductal system in the gland and the relationship of the gland to the platysma muscle were recorded. The CT scans of 12 patients with a tongue base carcinoma and 4 patients with a verified obstruction of the submandibular duct were also reviewed to establish how the glands are affected by extrinsic lesions. The normal glands measured 28 x 18 mm (+/- 5 mm) in the axial plane. Two patients with unilateral hypoplasia of the gland were found in the normal group. Visualization of the intraglandular duct is not a specific finding since it was observed in more than 25 per cent of the normal group. Displacement and bulging of the platysma muscle by the submandibular gland can be a sign of glandular enlargement. It was also seen in 9 out of 12 patients with carcinoma of the base of the tongue.