Meta-analysis and literature review of techniques to achieve hemostasis in endoscopic sinus surgery.

BACKGROUND: Functional endoscopic sinus surgery (FESS) has been used as the standard of treatment for sinonasal disease in which medical therapy fails to ameliorate the disease. Intraoperative hemostasis is a crucial factor in FESS. Currently, ideal techniques for creating intraoperative hemostasis have yet to be clarified and standardized. We sought to better understand what variables can affect intraoperative blood loss and therefore improve surgical field outcomes. METHODS: A literature search was conducted using PubMed, OVID, MD Consult, and Micromedex with keywords including: FESS, intraoperative blood loss, hemorrhage, and vasoconstriction. The articles were then evaluated with regard to blood loss, surgical grade, and operative time. Eleven articles were cross-referenced to determine the most statistically significant techniques in 3 main categories: general anesthetics, preoperative steroids, and use of epinephrine. RESULTS: Analysis of the articles indicate that total intravenous anesthesia (TIVA) is statistically more beneficial than balanced anesthesia (BA), providing an average difference in blood loss of 75.3057 mL; the use of preoperative steroids is statistically more beneficial than placebo, with an improved difference in blood loss of 28 mL; and a trend toward hemostasis with the use of local anesthetics at a concentration of 1:200,000. CONCLUSION: Meta-analysis of 1148 patients concludes that hemostasis during FESS is best conducted using TIVA, preoperative steroids, and topical local anesthetic at a 1:200,000 concentration.

A novel use of a landmark to avoid injury of the anterior ethmoidal artery during endoscopic sinus surgery.

BACKGROUND: The aim of this study was to describe and correlate radiographically the anterior ethmoidal artery (AEA) to useful endoscopic surgical landmarks, such as the nasal beak (NB), nasal crest (NC), and axilla of the middle turbinate, because these are commonly encountered during endoscopic sinus surgery and skull base surgery. METHODS: A retrospective review and software analysis was performed by three independent observers. Measurements of distance and angulation from the AEA to the NC, NB, and axilla of the middle turbinate were performed. A total of 138 unique computed tomography (CT) scans performed at a university tertiary care center were evaluated. RESULTS: The average age of the patients whose scans were analyzed was 50.5 (range, 17-90 years) years of age. The gender distribution was 61 male and 89 female patients. After comparing the measurements to the three landmarks noted, it was determined that the NB had the most interpatient concordance and the least interobserver variability. The average distance between the NB and the AEA as it penetrates the lamina papyracea is 2.34 cm (variance, 0.07) at an angle of 45.21° from the Frankfurt horizontal line. CONCLUSION: The real advantage of this novel use of the NB as a landmark to identify the AEA is that it is easy to use, unobtrusive, and is not time-consuming. This relationship between the NB and the AEA is consistent across genders and ethnicities and is more valuable than others presented previously, which may be more variable.

Proteomic signatures of epidermal growth factor receptor and survival signal pathways correspond to gefitinib sensitivity in head and neck cancer.

PURPOSE: Gefitinib targeting of the epidermal growth factor receptor (EGFR) has shown limited activity in clinical trials of head and neck squamous cell carcinoma (HNSCC). To investigate the underlying molecular mechanism, the proteomic signatures and responses of EGFR and downstream signals have been studied in a panel of HNSCC cell lines and tumor specimens pre- and post-gefitinib treatment. EXPERIMENTAL DESIGN: The IC(50) of gefitinib for HNSCC cell lines were determined using 3-(4,5-dmethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide proliferation assay. The effects of gefitinib on activation of EGFR and downstream signaling molecules were determined by Western blot, ELISA, and reverse-phase protein microarray (RPMA). The biomarkers involved in the signaling pathways were examined in HNSCC tumor specimens from patients in a phase I gefitinib trial. RESULTS: In vitro, gefitinib inhibited cell proliferation with differing IC(50), and suppressed activation of EGFR and downstream signaling molecules protein kinase B (AKT), extracellular signal-regulated kinase 1/2, signal transducer and activator of transcription 3 (STAT3), and nuclear factor kappaB. The drug sensitivity was statistically correlated with activation of phosphorylated AKT (p-AKT) and phosphorylated STAT3 (p-STAT3) detected by ELISA, and consistent with results measured by RPMA. In patient samples, a broad suppression of activation of EGFR and downstream signaling molecules was observed in a molecular responder patient, in contrast to a lack of inhibition or increased activation of biomarkers in different pathways in nonresponder patients. CONCLUSIONS: Gefitinib sensitivity is correlated with p-AKT and p-STAT3 activation in HNSCC cell lines and tumor specimens. p-AKT and p-STAT3 could serve as potentially useful biomarkers and drug targets for further development of novel therapeutic agents for HNSCC.

Deficient TP53 expression, function, and cisplatin sensitivity are restored by quinacrine in head and neck cancer.

PURPOSE: To determine the nature and potential pharmacologic reversibility of deficient TP53 expression and function in head and neck squamous cell carcinomas (HNSCC) with wild-type TP53, previously associated with decreased sensitivity to cisplatin therapy. EXPERIMENTAL DESIGN: TP53 genotype, mRNA and protein expression, TP53-induced p21 expression, and TP53 DNA-binding and reporter gene function were determined in a panel of nine previously characterized HNSCC cell lines from the University of Michigan squamous cell carcinoma (UM-SCC) series. The genotoxic drug doxorubicin and the anti-inflammatory and antimalarial drug quinacrine, previously identified as inducers of TP53, were used to examine the nature and potential reversibility of deficient TP53 expression and function. The specific role of inducible TP53 on function and cellular proliferation was confirmed using selective TP53 inhibitor pifithrin-alpha or short hairpin RNA knockdown. The capability of quinacrine to sensitize HNSCC to the cytotoxic effects of cisplatin was assessed. RESULTS: UM-SCC cell lines with wild-type TP53 genotype underexpressed TP53 mRNA and protein when compared with normal human keratinocytes or UM-SCC with mutant TP53. Although doxorubicin failed to induce TP53 expression or functional activity, quinacrine induced TP53 mRNA and protein expression, increased TP53 reporter activity and p21 protein expression, and induced growth inhibition in these wild-type TP53 cell lines. Quinacrine-induced TP53 reporter activity and growth suppression were attenuated by pifithrin-alpha and TP53 short hairpin RNA knockdown. Furthermore, quinacrine sensitized UM-SCC to cisplatin in vitro. CONCLUSIONS: Deficient TP53 mRNA and protein expression underlies decreased function in a subset of HNSCC with wild-type TP53 and can be restored together with cisplatin sensitization by quinacrine.

Soluble CD44 is a potential marker for the early detection of head and neck cancer.

INTRODUCTION: Head and neck squamous cell carcinoma (HNSCC) is a devastating and deadly disease, largely because it is diagnosed in late stage. Cure rates, currently at 50%, could increase to >80% with early detection. In this study, we evaluate soluble CD44 (solCD44) as an early detection tool for HNSCC by determining whether it reliably distinguishes HNSCC from benign disease of the upper aerodigestive tract. METHODS: We carried out the solCD44 ELISA on oral rinses from 102 patients with HNSCC and 69 control patients with benign diseases of upper aerodigestive tract to determine the sensitivity and specificity of the test for differentiating HNSCC from benign disease. Furthermore, we did a pilot study using methylation-specific PCR primers on oral rinses from 11 HNSCC patients with low solCD44 levels and 10 benign disease controls. RESULTS: Mean salivary solCD44 levels were 24.4 +/- 32.0 ng/mL for HNSCC patients (range, 0.99-201 ng/mL) and 9.9 +/- 16.1 ng/mL (range, 0.73-124 ng/mL) for the patients with benign disease (P < 0.0001). Depending on cutoff point and HNSCC site, sensitivity ranged from 62% to 70% and specificity ranged from 75% to 88%. Nine of 11 HNSCC and 0 of 10 controls with low solCD44 levels showed hypermethylation of the CD44 promoter. CONCLUSIONS: SolCD44 is elevated in the majority of HNSCC and distinguishes cancer from benign disease with high specificity. Whereas the solCD44 test lacks sensitivity by itself, methylation status of the CD44 gene seems to complement the solCD44 test. Our pilot data indicate that, together, these markers will detect HNSCC with very high sensitivity and specificity.

The benign lymphoepithelial cyst and a classification system for lymphocytic parotid gland enlargement in the pediatric HIV population.

OBJECTIVES/HYPOTHESIS: The objectives of this study are to present a series of parotid gland benign lymphoepithelial cysts (BLEC) in HIV-positive children and to propose a three-tiered classification system for HIV-associated lymphocytic parotid gland enlargement. STUDY DESIGN: The authors conducted a retrospective case series and literature review. METHODS: The authors conducted a retrospective chart review of four pediatric patients with HIV-associated parotid gland BLEC who presented to a tertiary care university medical center. RESULTS: Four pediatric HIV-positive patients (four girls; age range, 7-17 years [mean age, 12.8 years]) were diagnosed with parotid gland BLEC. Two patients presented with acute parotitis and the others presented with asymptomatic enlargement of the parotid glands. Three patients had bilateral parotid gland BLEC. The other patient demonstrated persistent generalized lymphadenopathy (PGL) of the intraparotid and cervical lymph nodes and early BLEC limited to the left parotid gland. One patient also displayed parotid gland microcalcifications and cystic changes in the adenoids, neither of which have been described previously in the setting of HIV-associated BLEC. Computed tomography was performed on all patients, and one patient underwent fine needle aspiration to confirm the diagnosis. All patients opted for observation and antiretroviral medication therapy as long-term treatment. Based on these findings and a review of the literature, we propose a three-tiered classification system for lymphocytic parotid gland enlargement in the HIV population: 1) PGL, 2) benign lymphoepithelial lesions (BLEL), and 3) BLEC. CONCLUSIONS: This series equals the largest pediatric series of HIV-associated parotid gland BLEC in the English literature. One patient in our series also demonstrated PGL; there were no cases of BLEL. A classification system based on morphology is proposed to help resolve the confusion in terminology used to describe this entity. Most pediatric HIV-infected patients with parotid gland BLEC can be treated with observation and antiretroviral medication therapy. For others, who are symptomatic or more concerned about their cosmetic appearance, sclerotherapy may offer a reasonable option. Radiation therapy and surgery should be reserved for select cases.

Management of pediatric airway granular cell tumor: role of laryngotracheal reconstruction.

OBJECTIVE: To discuss the role of laryngotracheal reconstruction (LTR) in granular cell tumor (GCT) and to highlight the importance and seriousness of GCT in pediatric airway cases. METHODS: A historical literature review was performed and a GCT case from the University of Miami Pediatric Otolaryngology Clinic is presented to highlight the role of LTR in the treatment of GCT. RESULTS: A case of a GCT of the laryngotracheal airway is reported and the management is discussed. Histological discussion and a review of the literature are included regarding GCT. This case is the third reported in the English literature of two synchronous GCT lesions of the upper airway repaired with a laryngotracheal reconstruction. CONCLUSIONS: In the authors' experience once conservative management consisting of endoscopic debulking has failed the treatment of choice for GCTs of the pediatric airway that are unresectable is a single stage laryngotracheal reconstruction with negative frozen section pathology to assure total wide local excision.