The role of topical antibiotic prophylaxis in patients undergoing contaminated head and neck surgery with flap reconstruction.

OBJECTIVES/HYPOTHESIS: Patients undergoing contaminated head and neck surgery with flap reconstruction have wound infection rates of 20% to 25% with parenteral antibiotic prophylaxis. Studies suggest that perioperative antimicrobial mouthwash reduces oropharyngeal flora and may prevent wound infections. We hypothesized that the addition of topical antibiotics to a parenteral prophylactic regimen would reduce the incidence of wound infection in these high-risk patients. STUDY DESIGN: We performed a randomized, prospective clinical trial. METHODS: Patients received either 1) parenteral piperacillin/tazobactam (3.375 g every 6 hours for 48 h) or 2) parenteral piperacillin/tazobactam plus topical piperacillin/tazobactam administered as a mouthwash immediately before surgery and once a day for 2 days postoperatively, with piperacillin/tazobactam added to the intraoperative irrigation solution. The wounds of all patients were evaluated daily using predefined objective criteria. RESULTS: Sixty-two patients met inclusion criteria and were enrolled in the study. The overall wound infection rate was 8.1% (95% confidence interval [CI], 2.7%-17.8%). Two of 31 patients (6.4%) who received parenteral antibiotics alone developed a wound infection compared with 3 of 31 patients (9.7%) randomly assigned to receive topical plus parenteral antibiotics. This difference was not statistically significant (P = >.05). Infection rate was not associated with flap type (rotational vs. free tissue transfer), mandibular reconstruction, age, gender, tumor site, stage, surgical duration, or blood loss. CONCLUSIONS: These results suggest that piperacillin/tazobactam is a highly effective antibiotic for prevention of wound infection in patients undergoing flap reconstruction following contaminated head and neck surgery. However, the addition of topical piperacillin/tazobactam does not appear to enhance the prophylactic benefit of parenteral antibiotics alone.

Prevalence of herpes simplex virus in malignant laryngeal lesions.

OBJECTIVE: To determine the prevalence of herpes simplex virus (HSV) in malignant laryngeal lesions. STUDY DESIGN: Retrospective review. MATERIALS AND METHODS: Paraffin-embedded, histologically confirmed specimens containing benign laryngeal lesions, squamous cell carcinoma of the larynx, and squamous cell carcinoma of the oral cavity were identified from archived surgical specimens. Biopsies of normal-appearing oral cavity tissue were also obtained from fresh-frozen cadavers. These tissues were analyzed for the presence of HSV DNA using polymerase chain reaction techniques. Patient charts were reviewed for patient demographics, risk factors, stage, clinical course, treatment, and outcome. RESULTS: HSV was detected in nine laryngeal squamous cell carcinomas (75%) and in none of the benign laryngeal lesions (P = .0001). HSV was also found in three oral cavity squamous cell carcinomas (25%) and in none of the controls (P = .049). CONCLUSION: HSV is more prevalent in squamous cell carcinoma of the larynx and oral cavity than in their respective control groups, suggesting a role for carcinogenesis. HSV is more prevalent in squamous cell carcinoma of the larynx than of the oral cavity. Further studies to determine the role of HSV as a cocarcinogen and its interrelationship with other environmental factors in laryngeal cancer are warranted.

FNAC in the diagnosis of recurrent dermatofibrosarcoma protuberans of the forehead. A case report.

BACKGROUND: Dermatofibrosarcoma protuberans is a rare cutaneous soft tissue tumor of intermediate malignant potential with a characteristic tendency for recurrence. Metastases are unusual. This tumor usually occurs in the trunk and extremities and, infrequently, on the face and scalp. Its cytologic appearance on fine needle aspiration has only been rarely reported. It is characterized by numerous fibroblastlike cells that arrange as single cells or in clusters of spindle cells arrayed in a storiform pattern. CASE: A 42-year-old male presented with a one-year history of an enlarging left forehead mass (lateral brow) that was adjacent to an old surgical scar. Fine needle aspiration revealed a low grade spindle cell neoplasm morphologically identical to a dermatofibrosarcoma protuberans excised 15 years earlier, indicating tumor recurrence. CONCLUSION: Distinguishing dermatofibrosarcoma protuberans from other spindle cell tumors and fibrohistiocytic lesions may pose significant challenges to the pathologist. However, in the appropriate clinical setting and applying strict diagnostic criteria, fine needle aspiration cytology is a reliable tool in establishing the diagnosis of this neoplasm.

Repair of laryngeal fractures using adaptation plates.

BACKGROUND: There is a need to evaluate the effectiveness of laryngeal fracture repair using rigid adaptation plates. METHODS: A retrospective chart review of patients undergoing open repair of laryngeal fractures using metal alloy plates, from 1987 to 1995, was performed. Postoperative airway, deglutition, and voice were assessed. Postoperative follow-up ranged from 1 to 58 months (median, 27 months). All 10 patients sustained blunt or penetrating laryngeal trauma. After patients were resuscitated according to the ABC principles recommended by the American College of Surgeons, each underwent open repair of laryngeal fractures using rigid adaptation plates. RESULTS: Outcome was measured by perceptual analysis of the postoperative airway, swallowing, and voice, as well as biocompatibility. Ten patients underwent repair and stabilization of the larynx using adaptation plates. Nine patients sustained blunt trauma, and one patient sustained penetrating trauma. Voice was subjectively graded as good if it resembled the preinjury status, fair if it differed, and poor if it represented aphonia, whisper, or unintelligible speech. Airway was graded as good if it resembled preinjury status, fair if mild exercise intolerance or aspiration existed, and poor if the patient could not be decannulated. Nine patients had a good airway following repair, and six of seven patients requiring tracheotomy were decannulated. All patients tolerated the plates well and suffered no surgical complications. CONCLUSION: Repair of the laryngeal framework using adaptation plates provides adequate, immediate stabilization with restoration of function and is an alternative to traditional methods of repair.

Laryngeal framework surgery for the management of aspiration in high vagal lesions.

PURPOSE: The purpose of this study is to ascertain the effectiveness of laryngeal framework surgery, including medialization thyroplasty (MT), with or without arytenoid adduction (AA), on preventing aspiration, improving diet, and aiding in the subsequent decannulation of individuals with high vagal lesions. PATIENTS AND METHODS: A retrospective chart review was performed on each patient presenting with a high vagal lesion who was treated with laryngeal framework surgery from June 1992 to April 1996 at a university medical center. Thirty-five patients were identified; there were 20 women and 15 men, with a median age of 51. Information regarding etiology of the lesion, characteristics of the vocal cord deficits, degree of aspiration, the presence of other neurologic deficits and concurrent pulmonary disease, treatment, and outcome was obtained. The final outcome regarding voice, the presence and degree of aspiration, diet, and decannulation following MT, with or without AA, was assessed to determine the effectiveness of these procedures. RESULTS: Thirty-five patients underwent 40 MTs and 19 AAs. Ninety-four percent of patients who experienced aspiration improved, and 79% who had required tracheotomy were decannulated. Ninety percent of patients were noted to have subjective improvement in voice postoperatively. CONCLUSION: Laryngeal framework surgery improves airway, deglutition, and voice in individuals suffering from high vagal lesions, and facilitates the rehabilitation of these patients.

Pediatric respiratory papillomatosis: prognostic role of viral typing and cofactors.

Children with recurrent respiratory papillomatosis vary greatly in their clinical disease course. Many have mild disease with eventual remission while others present with an early aggressive airway obstructive course. This study consisted of 24 pediatric patients whose specimens underwent polymerase chain reaction analysis for cytomegalovirus (CMV), herpes simplex virus (HSV), and human papillomavirus (HPV) type. Nineteen of 24 specimens contained enough DNA for this study. None of the specimens were found to contain DNA from HPV-16, -18, -31, -33; CMV; or HSV, which contrasts with our previous findings in adults. Ten patients were infected by HPV-11 and seven of these underwent tracheotomy because of an aggressive tumorigenic clinical course. Nine patients were infected by HPV-6 alone of whom only two required a tracheotomy (P = 0.05, Fisher's Exact Test). The early airway obstructive course associated with HPV-11, however, had no bearing on achieving eventual disease remission, with decannulation achieved in eight of nine children.

The efficacy of tympanic electrocochleography in the diagnosis of endolymphatic hydrops.

Electrocochleography (ECoG), an objective electrophysiologic test, is useful in the clinical diagnosis of endolymphatic hydrops. The purpose of this study was further to define the role of ECoG in the diagnosis of this disease. A retrospective chart review of 100 patients undergoing tympanic ECoG was undertaken comparing symptoms, degree of hearing loss, duration of disease, and diagnosis with ECoG results. The apparent sensitivity and specificity of ECoG in the diagnosis of endolymphatic hydrops were determined to be 57% and 94%, respectively. Three of 30 positive ECoG results were falsely positive. Fluctuating hearing loss and the degree of hearing loss (< 40 dB) and duration of disease (< 48 months) were statistically significant in predicting positive ECoG results. We conclude that a positive ECoG result is helpful in objectively confirming the disease. However, a negative result does not rule out hydrops.

Adult respiratory papillomatosis: human papillomavirus type and viral coinfections as predictors of prognosis.

Pathologic material and the records of 29 patients with laryngeal papillomatosis were reviewed. The relationship between the type of human papillomavirus (HPV) and the presence of viral coinfections was correlated with clinical outcome. Using polymerase chain reaction, paraffin-embedded specimens were analyzed for the presence of HPV, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV). The HPV type could be identified in 24 patients' specimens. Twenty-one patients were infected with HPV type 6. The other 3 were infected with HPV type 11 or 16. Three patients developed squamous cell carcinoma, of whom 2 had HPV type 11 or 16. We found HSV, EBV, and CMV in 50%, 12.5%, and 0% of specimens, respectively. An aggressive clinical course was observed in 17 patients. Evidence of coinfection with other viruses was identified in 11 (65%) of these patients. In contrast, a benign clinical course was observed in 7 patients, of whom 2 (29%) had viral coinfections. We conclude that the HPV type and the presence of viral coinfections may be predictive of an aggressive clinical course.

Lowering extracellular calcium decreases the length of isolated outer hair cells.

Transduction by the inner hair cells is hypothesized to be modulated through a change in the length of the outer hair cells (OHC). It has been suggested that the slow change occurring in OHC length is mediated by an actin-myosin system requiring Ca2+ and ATP. This study was designed to systematically examine the effects of lowering extracellular Ca2+ on OHC length. OHCs were isolated from guinea pig cochleae, mechanically dissociated and dispersed, and placed in a Hank's balanced salt solution (HBS). Exposing the cells to a Ca(2+)-free HBS supplemented with 200 microns EDTA produced a shortening in OHC length with a concomitant increase in cell width. The shortening was reversed successfully by bathing the cells in 8 mM Ca2+. We speculate that the decrease in length due to lowering extracellular Ca2+ may be caused by a relaxation of a circumferential contractile mechanism which is thought to cause elongation of intact OHCs (Slepecky, 1989; Dulon et al., 1990).