Primary High-Grade Poorly Differentiated Angiosarcoma of an Intra-parotid Lymph Node.

Head and neck angiosarcoma is an infrequent malignant vascular tumor most commonly found in the skin and soft tissue of the head and neck. Most head and neck angiosarcomas are metastatic to cervical lymph nodes from other primitive location. We describe herein a case of primary high-grade poorly differentiated angiosarcoma arising in an intra-parotid lymph node, discuss the value of immunohistochemical stains for differential diagnosis, and review the literature concerning head and neck angiosarcoma. A 47-year-old man presented with a painless mass that had grown for a period of 6 months in the parotid area. The CT-scan revealed a left parotid lesion of 17 mm. Fine needle aspiration was considered suspicious for lymphoma or poorly differentiated carcinoma. A superficial parotidectomy was performed. On gross examination, the lesion was a well-defined, gray, homogeneous mass of 15 mm of diameter. Microscopic examination showed a normal parotid tissue and a poorly differentiated malignant neoplasm in an intra-parotid lymph node. The tumor had a pseudo-alveolar pattern, with large pleomorphic epithelioid cells, abundant eosinophilic cytoplasm, large vesicular nuclei, and one or more prominent nucleoli. Atypical mitoses were seen. Neoplastic malignant cells stained positive for Vimentin, CD31, D2-40, factor VIII, ERG, and partially for CD34. A positron emission tomography scan was made to search for a primary neoplasia, but no other tumor was localized. The diagnosis of primary high-grade, poorly differentiated, intra-parotid lymph node angiosarcoma was established.

Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental prospective study.

OBJECTIVE: This prospective experimental study evaluates the effectiveness of micropauses (MPs) to prevent muscular fatigue and its deleterious effect on surgeons during prolonged surgical procedures. BACKGROUND: Operating is a hazard for surgeon's health. Beyond acute injuries and blood-borne infections, back and neck pain is a poorly recognized factor causing chronic ailment in more than half the surgeons surveyed. MP, a 20-second break every 20 minutes, is an accepted strategy used widely in the workplace. METHODS: We designed a crossover experimental study. Sixteen surgeons were tested 3 times: once in a control situation before any surgery (CTL) and twice after a prolonged, reproducible operation (at least 2 hours), 1 of these with formal MP (WMP) the other without (WOMP). Muscular fatigue was tested by holding a 2.5-kg weight as long as possible with a stretched arm. Accuracy was evaluated with a device, measuring the mistakes made when following a predetermined path on a board. Finally, discomfort was measured by visual analog scale. RESULTS: We found a statistically and more importantly clinically significant difference between the CTL and WOMP groups in all 3 tests. MPs prevented completely or almost completely the effects of fatigue associated with surgery [accuracy (No. errors) CTL: 1.1, WOMP: 7.7, WMP: 1.7; fatigue (seconds) CTL: 137, WOMP: 92, WMP: 142]. CONCLUSIONS: Surgical procedures are associated with significant muscular fatigue that can be measured simply and which has a direct effect on comfort and surgical accuracy. More important, this effect is completely or almost completely prevented by MPs.

Suture restriction of the temporal bone as a risk factor for acute otitis media in children: cohort study.

BACKGROUND: Eustachian tube (ET) dysfunction plays an important role in the pathogenesis of acute otitis media (AOM). Unfortunately, there is a lack of knowledge about the exact role of the ET's bony support, the temporal bone, on occurrence of AOM. This study investigates whether severe suture restriction of the temporal bone is a risk factor for development of AOM in young children. METHODS: Using a prospective cohort design, 64 children aged 6 to 18 months without prior history of AOM were followed during the cold season (September 2009 to April 2010). Temporal bone status (categorized as with or without severe suture restriction) was evaluated using palpation and a cranial bone mobility test. Information about potential baseline confounders and risk factors for AOM (gender, age, birth weight, gestational age, use of pacifier, daycare attendance, presence of siblings, low socioeconomic status, breastfeeding ≥ 6 months, parental smoking and history of upper respiratory tract infection) were also collected. Occurrence of AOM diagnosed by physicians blinded to temporal bone status was the main outcome. Data were analyzed using hierarchical linear and nonlinear (multilevel) models. RESULTS: Severe suture restriction of the temporal bone was identified in 23 children (35.9%). At least one AOM episode was diagnosed in 14 (48.3%) of the ears associated with temporal bones previously identified as having severe suture restriction and in 28 (28.3%) of those without severe suture restriction. Higher risk for AOM was explained by severe suture restriction of the temporal bone (adjusted relative risk (RR), 2.26, 95% CI 1.43 to 2.91, p<.01), pacifier use (RR, 2.59, 95% CI 1.51 to 3.22, p<.01) and younger age (RR, 0.22, 95% CI 0.10 to 0.52, p=.001). CONCLUSIONS: The study results indicate that severe suture restriction of the temporal bone is a risk factor for AOM in young children. Subsequent intervention studies are needed to determine if this mechanical risk factor can be modified in young children.

Otologic safety of manuka honey.

OBJECTIVE: To investigate the possible ototoxic effects of a 50% concentration of manuka honey in a chinchilla animal model. STUDY DESIGN: A prospective, controlled animal study. SETTING: The Research Institute of the Montreal Children's Hospital, McGill University Health Centre. SUBJECTS AND METHODS: Eight animals had myringotomy incisions in both ears. One ear was randomly assigned to receive the 50% manuka honey solution. The contralateral ear received saline and served as the control ear. OUTCOME MEASURES: Auditory brainstem evoked responses (ABRs) were measured bilaterally for a wide range of frequencies (between 8 and 25 kHz) before and 2 weeks after transtympanic manuka honey and saline application. The animals were sacrificed, and all cochleae were dissected out and processed for light and scanning electron microscopy (SEM). RESULTS: The measured ABR thresholds after the application of 50% concentration of manuka honey revealed severe ototoxicity in all honey-exposed ears. This was accompanied by gross physical changes and histologic evidence of hair cell toxicity on SEM and light microscopy. The control ears remained unchanged during the period of the experiment. CONCLUSION: Although 50% concentration of manuka honey is the proven concentration to have bactericidal properties against biofilms of Pseudomonas aeruginosa and Staphylococcus aureus, this concentration appeared to have caused severe or intense inflammatory changes that produced facial paralysis, vestibulotoxicity, and hearing loss.

Vocal cord adduction causing obstructive sleep apnea from vagal nerve stimulation: case report.

A recognized complication of vagal nerve stimulation is new or worsening sleep apnea. Its pathophysiology is not clearly understood. We report a patient with obstructive sleep apnea that was directly associated with vagal nerve stimulation causing recurring vocal cord adduction. Adjusting the stimulator settings resolved the problem.

Radiation-induced xerostomia: is octreotide the solution?

OBJECTIVE: In this study, we looked for evidence that octreotide, a drug used specifically in acromegaly and other digestive pathologies, can have a radioprotective effect on salivary glands. This effect has already been proven on the pituitary gland, which is why we postulated that octreotide could act the same way on rat parotid glands. METHOD: A prospective randomized controlled study on animals was conducted. With a noninvasive technique, we collected saliva from the parotid glands of 18 anesthetized rats at time 0 (preirradiation) and 1 month (postirradiation). Each sampling technique lasted 40 minutes, with pilocarpine injection at time 0 and 20 minutes. Saliva was collected bilaterally. Eighteen rats, nine in the saline group and nine in the octreotide group, were randomized. The substance was injected 30 minutes before irradiation. Thirty gray were given with the gamma knife on the left parotid gland of each rat following a computerized targeting method. Each gland was examined after the last saliva collection to determine the percentage of five criteria: fibrosis, ducts, fat, vessels, and acini. RESULTS: Data are available for 17 rats (nine in the octreotide group and eight in the saline group). Statistical analysis was done with a t-test (independent and paired). We noted that the postirradiation secretion in the left (radiated) gland was diminished compared with the right (nonradiated) gland in the saline group (p = .014). Fibrosis was increased in the irradiated (left) gland in both groups (p = .024 in the octreotide group and p = .033 in the saline group). The percentage of duct cells was more important in the left (radiated) gland of the octreotide group (p = .046). A trend appeared for a decrease in acinic cells only in the control group (p = .063). CONCLUSION: Octreotide acted as a radioprotective agent on rat parotid glands 1 month after irradiation with 30 Gy given with the gamma knife.

Mechanisms of active laryngeal closure during noninvasive intermittent positive pressure ventilation in nonsedated lambs.

The present study stems from our recent demonstration (Moreau-Bussiere F, Samson N, St-Hilaire M, Reix P, Lafond JR, Nsegbe E, Praud JP. J Appl Physiol 102: 2149-2157, 2007) that a progressive increase in nasal intermittent positive pressure ventilation (nIPPV) leads to active glottal closure in nonsedated, newborn lambs. The aim of the study was to determine whether the mechanisms involved in this glottal narrowing during nIPPV originate from upper airway receptors and/or from bronchopulmonary receptors. Two groups of newborn lambs were chronically instrumented for polysomnographic recording: the first group of five lambs underwent a two-step bilateral thoracic vagotomy using video-assisted thoracoscopic surgery (bilateral vagotomy group), while the second group, composed of six lambs, underwent chronic laryngotracheal separation (isolated upper airway group). A few days later, polysomnographic recordings were performed to assess glottal muscle electromyography during step increases in nIPPV (volume control mode). Results show that active glottal narrowing does not develop when nIPPV is applied on the upper airways only, and that this narrowing is prevented by bilateral vagotomy when nIPPV is applied on intact airways. In conclusion, active glottal narrowing in response to increasing nIPPV originates from bronchopulmonary receptors.

Obstructive sleep disordered breathing in children: beyond adenotonsillectomy.

Traditionally, adenotonsillectomy (AT) has long been the treatment of choice for obstructive sleep disordered breathing (SDB) in children. AT is usually considered a safe procedure, which cures 80% of children with SDB. Accumulated data have however challenged this overly simplistic view. Indeed, AT is invariably associated with significant morbidity, post-operative pain, and a mortality rate which, though low, cannot be ignored. In addition, aside from a recurrence of SDB at adolescence in an unknown percentage of cases, some recent results suggest that complete SDB cure is not achieved in as much as 75% of cases after AT. Interestingly, several treatment options have been recently proposed for replacing or complementing AT. Continuous positive airway pressure (CPAP) is now suggested in children with remaining SDB after AT; however, compliance and suitability of equipment remain important hurdles, especially in small children and infants. Anti-inflammatory treatments, including nasal glucocorticoids and/or the anti-leukotriene montelukast, appear to hold great promise. Finally, orthodontic treatments are an appealing option, with recent results in children suggesting that it is possible to improve or perhaps even cure SDB in a durable manner by enlarging the nasal passages and/or the oropharyngeal airspace. In conclusion, while we are currently in the midst of an exciting time with several new treatments being developed for childhood SDB, randomized controlled trials are urgently needed to delineate their indications. In the meantime, it appears that systematic detection of orthodontic anomalies and better collaboration with maxillofacial specialists, including orthodontists and/or dentists, is needed for deciding the best treatment options for childhood SDB.

Origins of the inhibiting effects of nasal CPAP on nonnutritive swallowing in newborn lambs.

The present study investigated the mechanism by which continuous positive airway pressure (CPAP) suppresses nonnutritive swallowing (NNS) during quiet sleep (QS) in newborn lambs. Eighteen full-term lambs were chronically instrumented and evenly distributed into three separate groups to determine the extent to which modulation of NNS may be attributed to stimulation of upper airway and/or bronchopulmonary mechanoreceptors. Six lambs were tracheotomized, six other lambs underwent a two-step bilateral intrathoracic vagotomy, and the remaining six lambs underwent chronic laryngotracheal separation (isolated upper airway group). Forty-eight hours after surgery, each nonsedated lamb underwent polysomnographic recordings on three consecutive days. States of alertness, NNS and respiratory movements were recorded. Results demonstrate that a CPAP of 6 cmH(2)O inhibited NNS during QS while administered directly on the lower airways and that bivagotomy prevented this inhibition. However, application of CPAP on the upper airways only also inhibited NNS during QS. Finally, the application of a CPAP of 6 cmH(2)O had no systematic effect on NNS-breathing coordination (assessed by the respiratory phase preceding and following NNS). In conclusion, our results suggest that bronchopulmonary receptors are implicated in the inhibiting effects of nasal CPAP of 6 cmH(2)O on NNS in all our experimental conditions, whereas upper airway receptors are only implicated in certain conditions.

Pain management after tonsillectomy: morphine is not enough.

INTRODUCTION: Tonsillectomy is usually done as day surgery, transferring to the parents most of the postoperative care. They often feel alone and incompetent in front of a child in pain. We developed a guide to help parents for both the evaluation and the management of postoperative pain. OBJECTIVE: To improve pediatric posttonsillectomy pain management with the implementation of a parental guide and treatment algorithm. METHODS: Eighty children (5-17 years) were recruited in this randomized clinical trial. Parents and children were assigned to one of the research groups: control or experimental. All received an identical prescription for acetaminophen (15 mg/kg) and morphine (0.3 mg/kg), information about the medication, a visual analogue scale (VAS), and index cards to be filled at home. The experimental group also received a treatment algorithm associating pain scores with analgesics. RESULTS: Pain scores for the control group and the experimental group were 5.3 and 4.7 on the day of surgery, 4.0 and 3.6 the next day, 2.2 and 2.3 3 days later, and 1.6 and 1.4 1 week after the intervention, respectively. The side effects and the analgesics given were comparable for both groups. CONCLUSION: No significant difference was demonstrated for the studied parameters, probably because the majority of the parents followed the prescriptions well. The guide was much appreciated. The children understood the VAS easily and liked using it. The combination of acetaminophen-morphine needs to be revisited since pain remains problematic.

Comparative study of acetaminophen-morphine versus rofecoxib-morphine for post-tonsillectomy pain control.

INTRODUCTION: Although we routinely use morphine at our institution, moderate to severe pain often persists for several days after tonsillectomy. Nonsteroidal anti-inflammatory drugs could offer significant relief. Unfortunately, concerns about increased risk of bleeding limit their use. Selective inhibitors of cyclooxygenase type 2 (COX-2), such as rofecoxib, which do not affect bleeding time, could be an interesting option. OBJECTIVE: To evaluate the efficiency and safety of "rofecoxib-morphine" versus "acetaminophen-morphine" for post-tonsillectomy pain control. METHOD: Eighty children (5-17 years old) took part in this prospective comparative study. Forty children were in the acetaminophen-morphine group (group A), and the remaining 40 children were in the rofecoxib-morphine group (group R). Pain scores, administered doses of medication, side effects, and the general health status of the child were collected by telephone calls made on the first, third, and seventh days after surgery. RESULTS: Pain scores for group A compared with group R are as follows: day 0 at home arrival, 4.6 to 2.5; day 0 average, 4.7 to 3.3; day 1, 3.6 to 2.6; day 3, 2.3 to 1.4; and day 7, 1.4 to 2.0. Moreover, children who received rofecoxib generally drank, ate, and returned to their regular activities more quickly than the children of group A. No side effects were reported with rofecoxib. CONCLUSION: Rofecoxib (COX-2 inhibitor) significantly reduces pain scores after pediatric tonsillectomy. The combination of rofecoxib and morphine is safe and helps children return more quickly to their activities.

Non-nutritive swallowing and respiration coordination among states of alertness in adult sheep.

Swallowing is a powerful inhibitor of respiration. Its coordination with respiration is therefore crucial to avoid aspiration and apnea. The aim of this study was to determine the coordination between non-nutritive swallowing (NNS) and phases of the respiratory cycle, including the assessment of the effect of states of alertness in adult sheep. Six animals were surgically instrumented under general anesthesia to record electroencephalography, electro-oculography (state of alertness), diaphragmatic electromyography (EMG), nasal flow (respiration), esophageal EMG, and the thyroarytenoid muscle (NNS). Our results revealed that (1) the highest NNS frequency is observed in rapid eye movement (REM) sleep, especially for bursts of NNS; (2) while NNS begins mainly during inspiration in all states of alertness, REM sleep, however, is responsible for an increase in the proportion of NNS beginning in expiration; (3) the link between inspiration and NNS is not affected by rumination. In conclusion, the link between NNS and inspiration in adult sheep is similar to that of lambs but contrary to previous reports on NNS induced by water in humans. Whether these differences are related to interspecies differences or the experimental techniques clearly needs further studies on spontaneous NNS in humans.

First myringotomy with insertion of a modified Goode T-Tube: changing the perforation paradigm.

BACKGROUND: Goode T-Tubes (Medtronic Xomed, Inc) have a bad reputation because of their residual tympanic perforation rate. However, these long-term tubes are mostly used in patients with chronic middle ear problems. On the other hand, "safer," short-term tubes may need to be reinserted in up to 20% of children. OBJECTIVE: To demonstrate that modified Goode T-Tubes inserted at the first myringotomy in normal children leave a perforation rate comparable to the rate reported in the literature for short-term tubes and may be extracted safely in the outpatient clinic when eustachian tube function is thought to be adequate. METHOD: This prospective study followed 58 children (100 ears) who had their modified Goode T-Tubes electively removed in the clinic, from October 2003 to November 2004. RESULTS: We found only one persistent perforation at the third follow-up (mean time 5.2 months). The tubes had been in place for an average of 2.9 years. The perforation healing rate was inversely related to intubation duration. Adenotonsillectomy seemed to favourably influence the speed of healing. The perforations healed faster when tubes were inserted for chronic middle ear effusion compared with recurrent acute otitis media. Age, gender, and the site of intubation were not related to persistent perforation. All of the tubes spontaneously extruded (13) healed without perforation. CONCLUSION: Modified Goode T-Tubes inserted at the first myringotomy and electively extracted allow for a longer middle ear ventilation period and have a perforation rate comparable to that of short-term tubes.

Cognitive skills analysis, kinesiology, and mental imagery in the acquisition of surgical skills.

GOAL: Isolate and evaluate the impact of mental imagery on the acquisition of an emergency surgical technique. METHOD: We studied 44 first-year medical students performing a cricothyrotomy on a mannequin to determine the impact of teaching using mental imagery (MI) and/or kinesiology (KG) compared to the standard Advandec Trauma Life Support (ATLS) approach. Students were randomly assigned to one of three groups: MI and KG, KG alone or control (ATLS). Two weeks after the one-hour teaching session, they were evaluated with an OSCE testing the performance of the different steps of the technique, the time required and its fluidity. RESULTS: Total results (maximum: 25 marks) are as follows: KG + MI = 20.3 +/- 1.5 ; KG = 19.3 +/- 2.9 ; ATLS = 18.2 +/- 2.5. The only statistically significant difference for total results was in the use of MI and KG compared to the control group. Kinesiology alone or with mental imagery improved the fluidity of the performance. CONCLUSION: Many factors influence the acquisition of a surgical technique. This study showed that acquisition and performance of an emergency procedure (cricothyrotomy) was improved when mental imagery and kinesiology were combined to teach it.

Quality of life following surgical treatment of oculopharyngeal syndrome.

Oculopharyngeal syndrome is a hereditary disease mostly affecting French Canadians. Cricopharyngeal myotomy and blepharoplasty are commonly performed on these patients. We reviewed the files of 20 patients who underwent these procedures between June 1986 and June 1999. The average perioperative stay was 4.7 days. The nine patients still alive were contacted and answered a telephone survey on their quality of life. None reported postoperative complications. Myotomy significantly improved the medical domain of their quality of life as confirmed by improvement in the dysphagia for solids, food incarceration, duration of meals, and choking during meals. The psychological domain also improved, namely, appetite and interest in food. The effects of blepharoplasty were also notable. Long-term satisfaction is reported by the majority of patients up to a maximum of 10 years postoperatively. In conclusion, simple procedures such as blepharoplasty and cricopharyngeal myotomy greatly improved the quality of life of these patients. We therefore recommend early interventions.

Effects of C fiber blockade on cardiorespiratory responses to laryngeal stimulation in concious lambs.

The primary aim of the study was to explore cardiorespiratory reflexes originating from laryngeal C fiber endings in the neonatal period. Seventeen lambs were instrumented for recording glottal adductor and diaphragm EMG, heart rate, systemic arterial pressure and respiratory movements. C fiber blockade was induced in eight lambs by 30 mg/kg capsaicin, the remaining nine lambs serving as controls. Cardiorespiratory reflexes were induced in non-sedated lambs by flowing air, menthol or 13% CO2, or by injecting water or 50 microg capsaicin in the laryngeal inlet through an endoscope. Responses to all stimuli but capsaicin were similar between the two groups. While cardiorespiratory responses were induced by capsaicin in control lambs, the responses were significantly inhibited in lambs with C fiber blockade. We conclude that laryngeal C fiber endings are functional and responsible for laryngeal chemoreflexes in newborn lambs.

The larynx and neonatal apneas.

OBJECTIVE: We sought to review the current literature on the role of the larynx in neonatal apneas. STUDY DESIGN: We conducted a literature search and analysis of the published and other available information on the topic. RESULTS: Publications on this topic in otolaryngology journals are rare, although more basic sciences-oriented journals have published interesting results from animal studies during the past 20 years. The scarce data on human neonates are also presented. CONCLUSIONS: The authors follow the phylogenetic and oncogenetic pathways to explain the active role of the larynx in neonatal apneas. Although most of these results are derived from animal studies, they certainly improve our understanding of human neonatal apneas.

Active upper airway closure during induced central apneas in lambs is complete at the laryngeal level only.

We tested the hypotheses that active upper airway closure during induced central apneas in nonsedated lambs 1). is complete and occurs at the laryngeal level and 2). is not due to stimulation of the superior laryngeal nerves (SLN). Five newborn lambs were surgically instrumented to record thyroarytenoid (TA) muscle (glottal constrictor) electromyographic (EMG) activity with supra- and subglottal pressures. Hypocapnic and nonhypocapnic central apneas were induced before and after SLN sectioning in the five lambs. A total of 174 apneas were induced, 116 before and 58 after sectioning of the internal branch of the SLN (iSLN). Continuous TA EMG activity was observed in 88% of apneas before iSLN section and in 87% of apneas after iSLN section. A transglottal pressure different from zero was observed in all apneas with TA EMG activity, with a mean subglottal pressure of 4.3 +/- 0.8 cmH2O before and 4.7 +/- 0.7 cmH2O after iSLN section. Supraglottal pressure was consistently atmospheric. Sectioning of both iSLNs had no effects on the results. We conclude that upper airway closure during induced central apneas in lambs is active, complete, and occurs at the glottal level only. Consequently, a positive subglottal pressure is maintained throughout the apnea. Finally, this complete active glottal closure is independent from laryngeal afferent innervation.

Active glottal closure during central apneas limits oxygen desaturation in premature lambs.

Our laboratory previously reported that active glottal closure was present in 90% of spontaneous central apneas in premature lambs while maintaining a high-apneic lung volume (Renolleau S, Letourneau P, Niyonsenga T, and Praud JP. Am J Respir Crit Care Med 159: 1396-1404, 1999.) The present study aimed at testing whether this mechanism limits postapnea oxygen desaturation. Four premature lambs were instrumented for recording states of alertness, thyroarytenoid muscle and diaphragm electromyographic (EMG) activity, nasal airflow, lung volume changes, and pulse oximetry. One thousand four hundred fifty-two spontaneous central apneas (isolated or during periodic breathing) were analyzed in nonsedated lambs. Apneas, with high lung volume maintained by active glottal closure, were compared with apneas, with a tracheostomy opened at apnea onset. Oxygen desaturation slopes were lower when high-apneic lung volume was actively maintained during both wakefulness and quiet sleep. Furthermore, oxygen desaturation slopes were lower after isolated apneas with continuous thyroarytenoid EMG during wakefulness, compared with apneas with noncontinuous thyroarytenoid EMG (= glottis opened shortly after apnea onset). These results highlight the importance of maintaining high-alveolar oxygen stores during central apneas by active glottal closure to limit desaturation in newborns.

Type III tympanoplasties: the Sherbrooke experience.

OBJECTIVES: To review short- and longer-term results of type III tympanoplasties as performed by the senior author and to compare these results with those reported in the literature. METHOD: Retrospective review of 96 type III tympanoplasties, with and without mastoidectomy, performed between April 1996 and August 2000. RESULTS: At a mean of 384 days postoperatively, 57.3% of patients had an air-bone gap of less than 20 dB. The average postoperative gap is 21.4 dB. Gap closure is best at 2000 Hz, with an average drop of 51% from initial value, compared with 34%, 39%, and 18% at 500, 1000, and 4000 Hz, respectively. CONCLUSION: Our results are similar to those published previously. We emphasize the improvement at 2000 Hz, which is an important frequency for speech discrimination. It would be interesting to see if it correlates with an improvement in quality of life.