Advances in Craniofacial Trauma

The epidemiology of craniofacial injury has changed significantly due to influences such as the advent of airbags and an increase in the sophistication of civilian weaponization. The emergency management of severe trauma has also evolved, leading to the survival of injuries that would have previously proved fatal. Together, these forces have had a notable impact on the challenges that surgeons treating craniofacial trauma now face.

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Copyright

ELSEVIER

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Forthcoming Issues

Cosmetic and Reconstructive Surgery of Congenital Ear Deformities

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Evidence-Based Medicine in Facial Trauma

This article provides the reader with a comprehensive review of high-level evidence-based medicine in facial trauma and highlights areas devoid of high-level evidence. The article is organized in the order one might approach a clinical problem: starting with the workup, followed by treatment considerations, operative decisions, and postoperative treatments. Individual injuries are discussed within each section, with an overview of the available high-level clinical evidence. This article not only provides a quick reference for the facial traumatologist, but also allows the reader to identify areas that lack high-level evidence, perhaps motivating future endeavors.

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Contents

Kris S. Moe

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Trauma in Facial Plastic Surgery

FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA

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Contributors

J. REGAN THOMAS, MD, FACS

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Advances in the Reconstruction of Orbital Fractures

Orbital reconstruction is one of the most challenging tasks for surgeons who treat craniofacial trauma. Suboptimal outcomes carry a high level of morbidity, with functional, emotional, and aesthetic implications. However, advances in reconstruction techniques, including the use of orbital endoscopy, computer-guided navigation, and mirror image overlay techniques, have been shown to provide significant improvements in outcomes. This article provides practical advice for applying these techniques to orbital reconstruction following trauma.

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Posttraumatic Laser Treatment of Soft Tissue Injury

Laser treatment for posttraumatic injury offers the clinician the unique opportunity for early intervention in mediating early scar formation, or for reducing the appearance of scars after maturation. In this review, the authors focus on the mechanisms by which lasers exert their therapeutic effects, highlighting several popular lasers and dosimetry used, and underscoring the power of combined surgical scar revision in managing posttraumatic facial scars.

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Issues in Pediatric Craniofacial Trauma

Pediatric maxillofacial fractures are rare owing to anatomic differences between juvenile and adult skulls. Children's bone is less calcified, allowing for "greenstick fractures." The overall ratio of cranial to facial volume decreases with age. In children, tooth buds comprise the majority of mandibular volume. The most common pediatric craniomaxillofacial fractures for children ages 0 to 18 years old are mandible, nasal bone, and maxilla and zygoma. Growth potential must be considered when addressing pediatric trauma and often a less-is-more approach is best when considering open versus closed treatment. Regardless of treatment, pediatric trauma cases must be followed through skeletal maturity.

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Eyelid and Periorbital Soft Tissue Trauma

Facial trauma often involves injuries to the eyelid and periorbital region. Management of these injuries can be challenging due to the involvement of multiple complex anatomic structures that are in close proximity. Restoration of normal anatomic relationships of the eyelids and periocular structures is essential for optimum functional and aesthetic outcome after trauma. This review provides an overview of the current literature involving soft tissue trauma of the eyelid and periorbital tissue, and highlights key steps in patient evaluation and management with various types of injuries.

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Emergent Soft Tissue Repair in Facial Trauma

Emergency personnel, surgeons, and ancillary health care providers frequently encounter soft tissue injuries in facial trauma. Appropriate evaluation and management is essential to achieve optimal functional and aesthetic outcomes.

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Current Management of Subcondylar Fractures of the Mandible, Including Endoscopic Repair

Treatment of subcondylar fractures has been the subject of debate for many years. Options for treatment include physical therapy, elastic maxillomandibular fixation, and open repair. Proper imaging and clinical evaluation are imperative when deciding on the best management option. In the past, most subcondylar fractures were treated with a closed approach. Recent data support open repair, when feasible. Studies show increased interincisal opening, lateral excursion, and protrusion with less mandibular shortening, jaw deviation, and pain. There are serious side effects that may be associated with open repair. The surgical technique for endoscopic repair is outlined in detail.

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Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

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Management of Zygomaticomaxillary Complex Fractures

Zygomaticomaxillary fractures account for approximately 25% of all facial fractures. They can be grouped into high-velocity and low-velocity injuries. A complete head and neck examination is critical for accurate clinical diagnosis. A thin-cut axial CT scan with sagittal, coronal, and 3-D reconstruction is important for accurate diagnosis and treatment planning. A thorough understanding of bony tetrapod anatomy and fracture mechanics is critical to treatment planning. Treatment options include closed and open reduction with internal fixation. Computer-aided applications can reduce the need for open reduction and improve the accuracy of both closed and open repairs.

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Correction of Nasal Fractures

Nasal fractures are the most frequently fractured facial bone from blunt facial trauma resulting in a significant number of patients seeking treatment. Proper evaluation and treatment in the acute setting can minimize secondary surgeries, lower overall health care costs, and increase patient satisfaction. Nasal fracture management, however, varies widely between surgeons. The open treatment of isolated nasal fractures is a particularly controversial subject. This review seeks to describe the existing literature in isolated nasal fracture management.

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Trauma in Facial Plastic Surgery

The optimal management of frontal sinus fractures remains controversial. Fortunately, the severity of these injuries has diminished with more stringent auto-safety regulations, changing the treatment paradigms used to repair these injuries. Appropriate patient selection and close follow-up may allow for conservative management strategies when dealing with frontal sinus fractures, largely replacing the more morbid and invasive techniques that have been the mainstay for years. Because acute and delayed sequelae can arise after the initial injury, patients should be thoroughly counseled about the importance of follow-up and the need to seek medical care if they develop any concerning signs or symptoms.

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Neurosurgical Considerations in Craniofacial Trauma

Spinal and traumatic brain injuries (TBIs) often accompany craniofacial trauma. Neurosurgical considerations can range from initial emergent surgery to conservative management of closed head injuries in patients with craniofacial injuries. This article discusses the most common disorders managed by neurosurgeons in the setting of craniofacial trauma, and reviews the usual timing and setting for various treatments that patients with TBI encounter throughout the course of treatment. It also highlights the consequences of TBI on the timing and planning of craniofacial repairs and the importance of multidisciplinary cooperation to provide comprehensive care to survivors of trauma.

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Sandwich compression with rubbery tourniquet sheets and cotton balls for auricular pseudocyst

Objectives/Hypothesis

Pseudocyst of the auricle is a benign, noninflammatory cystic disease that is more common in Asians than in Caucasians. When managed conservatively, the results are often unsatisfactory and recurrences are common. We aimed to introduce a novel modified surgical method that involves a deroofing technique followed by a sandwich compression suture using two rubber tourniquet sheets and an iodine-soaked cotton ball for the treatment of auricular pseudocysts and to ascertain its effectiveness.

Study Design

Case series with or without comparison.

Methods

The charts of 100 patients with auricular pseudocysts who were treated with this new method from 2004 to 2016 in a university-affiliated tertiary teaching hospital were retrospectively reviewed and analyzed.

Results

The mean patient age was 37.7 years, and 84% were male. All of the patients had unilateral lesions, with right-side lesions (53.0%) being slightly predominant. The cymba concha (44.1%) was the most common site. Seven patients (7.0%) had trauma to the ear within 3 months before presentation. Previous aspiration or drainage had been performed for the cysts in 35 patients (35.0%), and the recurrences had been treated conservatively. In comparison, 98 of the 100 patients recovered smoothly from surgery without further recurrence or complications after follow-up for at least 1 year.

Conclusions

Based on our experience, not only does this surgical procedure yield reliable results in the treatment of pseudocysts of auricles, but it also has advantages such as using readily available materials, being simple to perform, improving efficacy, and lowering recurrence rates.

Level of Evidence

4 Laryngoscope, 2017

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Adipose-derived mesenchymal stromal cells prevented rat vocal fold scarring

Objectives/Hypothesis

This study aimed to reveal the effects of adipose-derived mesenchymal stromal cells (ASCs) on prevention of vocal fold scarring by investigating how the immediate ASCs transplantation into the injured rat vocal fold affect the levels of gene transcription and translation.

Study Design

Prospective animal experiments with controls.

Methods

ASCs harvested from green fluorescent protein transgenic rat (ASCs group) or saline (sham group) were injected into the thyroarytenoid muscle of Sprague-Dawley rats immediately after stripping the vocal fold. For histological examinations, larynges were extirpated at 3, 14, and 56 days after the injection. Quantitative real-time polymerase chain reaction (PCR) analyses were performed at 3 and 14 days after the injection.

Results

Transplanted ASCs were detected only in larynges at day 3. At days 14 and 56, histological examination showed significantly higher amounts of hyaluronic acid and lower deposition of collagen in the ASCs group compared to the sham group. Real-time PCR revealed that the ASCs group showed low expression of procollagen (Col)1a1, Col1a3, matrix metalloproteinase (Mmp)1 and Mmp8 in each time points. The ASCs group showed high expression of fibroblast growth factor (Fgf)2 and Hepatocyte growth factor (Hgf) compared to the sham group at day 14.

Conclusions

ASCs increased expressions of Fgf2 and Hgf, and suppressed excessive collagen deposition during vocal fold wound healing. Given the fact that ASCs survived no more than 14 days, ASCs were thought to induce upregulations of growth factors' genes in surrounding cells. These results suggested that ASCs have potential to prevent vocal fold scarring.

Level of Evidence

N/A Laryngoscope, 2017

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Treatment of psoriasis with topical agents: Recommendations from a Tuscany Consensus

Abstract

Psoriasis is a chronic and relapsing inflammatory skin disease, clinically characterized by erythematous and scaly plaques. Treatment approach is mainly driven by disease severity, though several factors should be considered in order to identify the optimal therapeutic choice. Mild psoriasis may be treated with a wide array of topical agents including corticosteroids, vitamin D analogs, keratolytics, and calcipotriol/betamethasone propionate compound. Because guidelines may not provide practical indications regarding the therapeutic approach, the use of topical agents in psoriasis is more individually tailored. In order to homogenize the standard of care, at least in a local setting, we collected the real-life-based recommendations for the use of topical therapies from an expert panel, the Tuscany Consensus Group on Psoriasis, representing all leading centers for psoriasis established in Tuscany. With this document, this consensus group sought to define principles guiding the selection of therapeutic agents with straightforward recommendations derived from a real-life setting.

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Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature

Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatm...

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Evaluation of cutaneous rejuvenation associated with the use of ortho-silicic acid stabilized by hydrolyzed marine collagen

Summary

Background

Organic silicon plays an important role in dermal structure by promoting neocollagenesis. Thus, the supplementation of silicon in a highly bioavailable form can be used for skin rejuvenation.

Aims

This study aimed to evaluate skin changes associated with the use of ortho-silicic acid stabilized by hydrolyzed collagen.

Patients/Methods

Patients were randomized to receive 600 mg of ortho-silicic acid stabilized by hydrolyzed collagen (group 1, n = 11) or placebo (group 2, n = 11) to be taken 15 minutes before breakfast for 90 days. Clinical, photographical, and patients' subjective evaluations were conducted.

Results

A total of 22 patients were included. Clinical evaluations demonstrated changes in skin texture, firmness, and hydration statistically superior in group 1. Brightness, firmness, and overall appearance showed trends for a difference favoring group 1 according to patients' subjective evaluations. Objective images showed no statistical differences. No side effects, hypersensitivity, or systemic symptoms were observed in group 1. Treatment satisfaction in group 1 reached 80%.

Conclusions

Ortho-silicic acid stabilized by hydrolyzed collagen in a daily dose of 600 mg showed positive results in skin rejuvenation according to clinical evaluation in firmness, hydration, and skin texture. Further studies with larger and representative samples should be conducted to confirm our results.

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Comparative instrumental evaluation of efficacy and safety between a binary and a ternary system in chemexfoliation

Summary

Objective

To instrumentally evaluate the efficacy and the safety of a new ternary system chemo exfoliating formulation (water-dimethyl isosorbide-acid) vs traditional binary systems (water and acid) where the acid is maintained in both the systems at the same concentration.

Methods

Different peelings (binary system pyruvic acid and trichloroacetic acid—TCA, and ternary system pyruvic acid and TCA) were tested on the volar forearm of 20 volunteers of both sexes between 28 and 50 years old. The outcomes were evaluated at the baseline, 10 minutes, 24 hours, and 1 week after the peeling by means of noninvasive skin diagnosis techniques. In vivo reflectance confocal microscopy was used for stratum corneum evaluation, transepidermal waterloss, and Corneometry for skin barrier and hydration, Laser Doppler velocimetry in association with colorimetry for irritation and erythema analysis.

Results

The instrumental data obtained showed that the efficacy and safety of the new ternary system peel compounds were significantly higher compared with the binary system formulations tested. The new formulation peels improved chemexfoliation and reduced complications such as irritation, redness, and postinflammatory pigmentation compared to the traditional aqueous solutions.

Conclusion

The study showed that ternary system chemexfoliation, using a controlled delivery technology, was able to provide the same clinical effects in term of stratum corneum reduction with a significantly reduced barrier alteration, water loss, and irritation/erythema compared to traditional binary system peels.

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Anesthesia and Perioperative Care for Organ Transplantation.

No abstract available

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Acute Lung Injury and Repair: Scientific Fundamentals and Methods.

No abstract available

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Factors Influencing the Choice of Anesthesia as a Career by Undergraduates of the University of Rwanda.

No abstract available

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Administration of Hypertonic Solutions for Hemorrhagic Shock: A Systematic Review and Meta-analysis of Clinical Trials.

BACKGROUND: Several clinical trials on hypertonic fluid administration have been completed, but the results have been inconclusive. The objective of this study is to summarize current evidence for treating hypovolemic patients with hypertonic solutions by performing a systematic review and meta-analysis. METHODS: Major electronic databases were searched from inception through June 2014. We included only randomized controlled trials involving hemorrhagic shock patients treated with hypertonic solutions. After screening 570 trials, 12 were eligible for the final analysis. Pooled effect estimates were calculated with a random effect model. RESULTS: The 12 studies included 6 trials comparing 7.5% hypertonic saline (HS) with 0.9% saline or Ringer's lactate solution and 11 trials comparing 7.5% hypertonic saline with dextran (HSD) with isotonic saline or Ringer's lactate. Overall, there were no statistically significant survival benefits for patients treated with HS (relative risk [RR], 0.96; 95% confidence interval [CI], 0.82-1.12) or HSD (RR, 0.92; 95% CI, 0.80-1.06). Treatment with hypertonic solutions was also not associated with increased complications (RR, 1.03; 95% CI, 0.78-1.36). Subgroup analysis on trauma patients in the prehospital or emergency department settings did not change these conclusions. There was no evidence of significant publication bias. Metaregression analysis did not find any significant sources of heterogeneity. CONCLUSIONS: Current evidence does not reveal increased mortality when the administration of isotonic solutions is compared to HS or HSD in trauma patients with hemorrhagic shock. HS or HSD may be a viable alternative resuscitation fluid in the prehospital setting. Further studies are needed to determine the optimum volume and regimen of intravenous fluids for the treatment of trauma patients. (C) 2017 International Anesthesia Research Society

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The Little ICU Book, 2nd ed.

No abstract available

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Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response.

BACKGROUND: Blood product mistransfusions occur when a process error causes transfusion of incompatible blood products. These events are known sources of negative patient outcomes. One such event demonstrated an institutional knowledge gap and an opportunity to reduce this source of transfusion errors. The focus of this study was to evaluate the application of point of care cognitive aids to bridge potentially lethal knowledge gaps in blood product to patient compatibility. METHODS: A patient-donor ABO antigen compatibility grid for red blood cells (RBC) and fresh frozen plasma (FFP) was developed for creation of a cognitive aid and a blood product safety quiz. Participants included 117 registered nurses and postgraduate medical interns who were given 2 minutes to complete the quiz for establishing institutional controls. A separate group of 111 registered nurses and interns were given the same timed quiz twice, without and then with a blood product compatibility cognitive aid. An analysis of covariance was used to evaluate without cognitive aid versus with cognitive aid quiz results while taking the specialty (nurse versus interns) and baseline score into consideration. The blood bank adopted the grid as a forcing function to be completed before release of blood products. RESULTS: The correct RBC answer percentage increased from 84.7% to 98.3% without and with cognitive aid (average improvement 13.6%, standard deviation [SD] = 18.3%, 95% confidence interval, 10.1%-17.1%, P

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The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score >=10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful. (C) 2017 International Anesthesia Research Society

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Other Specialties Might Have a GPS.

No abstract available

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Doppler ultrasonography can be useful to determine the etiology of idiopathic sudden sensorineural hearing loss

This study aims to evaluate clinical features of both carotid and vertebral arteries in the idiopathic sudden sensorineural hearing loss (ISSNHL) patients and healthy individuals to contribute additional knowledge on vascular compromise theory.

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Lamina papyracea position in patients with nasal polypi: A computed tomography analysis

This study aimed to describe the positions of the lamina papyracea (LP) in patients who had nasal polypi, by computed tomography (CT) analysis.

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Accuracy of dermatoscopy for the diagnosis of nonpigmented cancers of the skin

Nonpigmented skin cancer is common, and diagnosis with the unaided eye is error prone.

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Allergic sensitization in American children of Middle Eastern ethnicity at age 2

Children of Middle Eastern ethnicity (MEE) born in the United States are seldom specifically examined in allergic disease research, and the prevalence of allergic sensitization in these children is unknown.1 For analyses, these children can be combined with white children not of MEE or excluded entirely because of the small sample, as we have previously done.2,3 However, this subgroup could have a unique set of cultural norms and/or environmental exposures that distinguish them from white, black, non–Middle Eastern, and non-Hispanic children with respect to allergic disease risk factors.

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Serum periostin during omalizumab therapy in asthma: a tool for patient selection and treatment evaluation

Omalizumab is an effective treatment for severe allergic asthma.1 Nevertheless, even in patients meeting the prescription criteria, lack of efficacy has been described as the most common reason for treatment discontinuation, at least in the real-life setting.2 An association between baseline serum periostin (SP) levels, evaluated before the start of treatment, and omalizumab efficacy has been recently described,3,4 suggesting the relevance of this molecule as a biomarker for patient selection and predictor of treatment response.

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mDCF + Avelumab in Resectable Esophago-gastric Adenocarcinoma (EGA)

Conditions:   Gastric Adenocarcinoma;   Esophageal Adenocarcinoma
Intervention:   Drug: mDCF + Avelumab
Sponsor:   McGill University Health Center
Not yet recruiting - verified September 2017

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Therapeutic Effect Of Luteolin Natural Extract Versus Its Nanoparticles On Tongue Squamous Cell Carcinoma Cell Line

Conditions:   Tongue Neoplasms;   Carcinoma
Interventions:   Drug: luteolin;   Drug: nano-luteolin
Sponsor:   Cairo University
Not yet recruiting - verified September 2017

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GR-MD-02 Plus Pembrolizumab in Melanoma, Non-small Cell Lung Cancer, and Squamous Cell Head and Neck Cancer Patients

Conditions:   Melanoma;   Non-Small Cell Lung Cancer;   Squamous Cell Carcinoma of the Head and Neck
Interventions:   Drug: GR-MD-02;   Drug: Pembrolizumab
Sponsors:   Providence Health & Services;   Galectin Therapeutics Inc.
Recruiting - verified September 2017

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Clinical Thyroidology High-Impact Articles

FREE ACCESS through October 3, 2017
Read Now:

Hypothyroid Symptoms in Pregnant Women Fail to Predict Hypothyroid Status
Elizabeth N. Pearce 

Conflicting Occurrence of Thyroid-Stimulating or Blocking Antibodies Is Seen in 4 to 9% of Patients with Autoimmune Thyroid Disease
Tim I. M. Korevaar

A Deiodinase 2 Polymorphism May Lower Serum T3 and Tissue T3 in Levothyroxine-Treated Patients
Jerome M. Hershman 

Is There a Distinct Pattern of Mutations in Benign Adenomatous Nodules?
Stephen W. Spaulding 

 

The post Clinical Thyroidology High-Impact Articles appeared first on American Thyroid Association.

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Corrigendum to “Niemann-Pick Disease Type C Presenting as a Developmental Coordination Disorder with Bullying by Peers in a School-Age Child”

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Study of factors responsible for recidivism in allergic fungal rhinosinusitis

Bipin Kishore Prasad, MS

Abstract

Patients with allergic fungal rhinosinusitis (AFRS) are typically atopic and immunocompetent. Despite combined modality treatment based on surgery and immunomodulation, the potential for recidivism is well recognized. A study was conducted in a military hospital in India to identify the factors responsible for recidivism in AFRS and to suggest measures to overcome it. Sixty patients with AFRS (42 new cases and 18 cases that required revision surgery) were managed between January 2009 and July 2013. Patients underwent endoscopic, radiologic, and laboratory evaluation for AFRS followed by functional endoscopic sinus surgery. Each patient received oral prednisolone, 1 mg/kg/day, for 1 week preoperatively and 0.5 mg/kg/day for 4 weeks postoperatively. A randomly selected group of 30 patients (group A) received oral prednisolone 0.4 mg/kg/day for the next 4 weeks, tapered to 0.2 mg/kg/day for the next 2 months and to 0.1 mg/kg/day for the last 2 months. The drug was stopped after 6 months. In the remaining 30 patients (group B), oral prednisolone was tapered within 2 months. Topical steroid sprays were advised in all patients. Recidivism was observed in 12 of 42 (28.6%) patients presenting for the first time with AFRS: 9 patients from group B (30%) and 3 patients from group A (10%). Besides inadequate postoperative oral steroid therapy, suboptimal functional endoscopic sinus surgery, noncompliance with intranasal sprays, nonadherence to Kupferberg staging, inadequate follow-up, failure of surgeons to impart health education to patients, and unavailability of ENT consultation in rural belts were found to be factors causing recidivism.

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Markers of proliferation and cytokeratins in the differential diagnosis of jaw cysts

Nikola D. Zivkovic, PhD; Dragan S. Mihailovic, PhD; Milos S. Kostic, PhD; Ana S. Cvetanovic, MD; Zaklina Z. Mijovic, PhD; Maja V. Jovicic Milentijevic, PhD; Tijana V. Dencic, MD

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Social media in otolaryngology-head and neck surgery

Modupe Oyewumi, MD; John Lee, MD, MSc, FRCSC; Allan Vescan, MD, FRCSC

Abstract

The objective of this study was to assess the current use of social media tools within Canadian otolaryngology-head and neck surgery (OHNS) programs and to assess the interest within these programs to integrate social media for networking, social, and educational programs. A prospective study from September 2013 to February 2014 was performed involving residents and faculty in Canadian OHNS programs. A 26-item questionnaire was created and sent to staff and resident physicians who met the study inclusion criteria using an online survey tool (surveymonkey.com). There were 101 respondents for a 10% response rate. More than half (58.4%) of respondents reported use of social media for personal and/or professional matters. Residents and junior faculty physicians 39 years and younger were more likely to have social media accounts and used them more frequently than their older counterparts. Among staff physicians, pediatric otolaryngologists had the highest rate of use, and otologists exhibited the lowest rate. Cellular phones were the most commonly used devices to access social media sites. Fewer than 35% of social media users failed to separate their personal and professional accounts. Although OHNS trainees and practicing physicians identified the potential benefits of social media tools in their specialty, most were unsure how to apply these tools to their practice. Ours is the first study to assess social media use in OHNS. Otolaryngologists are currently using social media; however, their application as a communication and educational tool in otolaryngology remains to be defined.

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Management decisions for Zenker diverticulum in the elderly

Karen Kost, MD, FRCSC; Kourosh Parham, MD

Zenker diverticulum is primarily a geriatric condition, usually requiring surgical management.

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Long-standing, near total tympanic membrane perforation

J. Scott Greene, MD, FACS

Although most spontaneous perforations heal, repeated ruptures and chronic suppuration can lead to permanent perforations.

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Hereditary hemorrhagic telangiectasia-laser treatment of epistaxis

Gorazd Poje, MD; Marcel Marjanovic Kavanagh, MD

Abstract

Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disorder characterized by recurrent epistaxis, telangiectasias, and multiorgan vascular dysplasia. Various modalities exist for the treatment of HHT-related chronic epistaxis, although no method is preferred over another. The aim of this study was to review the effectiveness of diode laser photocoagulation in the treatment of epistaxis in patients with HHT. The study included 17 patients (7 men, 10 women) treated with diode laser photocoagulation from year 2008 to 2012. All patients met the Curaçao criteria for a diagnosis of HHT. Patients were followed for 1 year. Treatment success was assessed using a custom questionnaire and total blood counts. After laser photocoagulation, the frequency and intensity of bleeds were reduced significantly and average hemoglobin concentrations improved at the 4-month assessment. After laser treatment, no patient required septodermoplasty; therefore, we suggest that every patient with HHT should be treated with laser photocoagulation. Diode laser treatment is a simple and effective procedure that should be considered when treating HHT.

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Congenital ear malformations: Effectively correcting cryptotia with neonatal ear molding

Collin Rozanski, BA; Joseph J. Rousso, MD

Cryptotia is a relatively common congenital ear malformation that can be difficult to correct with surgery. Treatment should be started before the first 6 weeks of life.

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Maxillary sinus mucoceles and other side effects of external-beam radiation in the pediatric patient: A cautionary tale

Anthony Sheyn, MD; Tate Naylor, MD; Felicity Lenes-Voit, MD; Eric Berg, MD

Abstract

A sinonasal mucocele can develop after the obstruction of a sinus ostium, which can occur secondary to trauma, infection, a neoplasm, or an iatrogenic cause. These mucoceles typically arise in the frontal and ethmoid sinuses. Sinonasal mucoceles are epithelium-lined cysts that can gradually expand to fill a paranasal sinus. They can present with ophthalmologic, rhinologic, and neurologic symptoms. There are reports in the literature of sinonasal mucocele development after radiation for nasopharyngeal carcinoma. However, these cases are rare; when they do occur, they tend to arise in the sphenoid sinus. We describe the case of a 21-year-old man who had undergone external-beam radiotherapy for a right maxillary sinus rhabdomyosarcoma at the age of 4 years and who subsequently developed bilateral maxillary sinus mucoceles and multiple other known complications of radiation therapy. To the best of our knowledge, this is the first case of postirradiation bilateral maxillary sinus mucoceles to be reported in the literature.

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Ear fetal rhabdomyoma

Lester D. Thompson, MD

The soft tissues of the orbit, ear, and oral cavity are the most frequent sites of involvement, although adult-type rhabdomyomas are more common in the parapharyngeal and laryngeal spaces.

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Endoscopy-assisted Coblation for nasopharyngeal stenosis: A report of 2 cases

Omer Karakoc, MD; Bahtiyar Polat, MD; M. Timur Akcam, MD; Mustafa Gerek, MD

Abstract

Acquired nasopharyngeal stenosis, the standard treatments for which carry a high risk of restenosis, is an uncommon complication of both velopharyngeal surgery and radiotherapy to the nasopharynx. We present the cases of 2 men, aged 41 and 52 years, who underwent surgical treatment for nasopharyngeal stenosis with endoscopy-assisted Coblation. The two surgeries lasted 23 and 18 minutes, respectively. Neither patient experienced any surgical complication, and a nasopharyngeal stent was not needed in either case. At follow-up 12 months postoperatively, both patients exhibited a patent nasopharyngeal passage. Endoscopy-assisted Coblation appears to be a safe, effective, and less painful option for the treatment of nasopharyngeal stenosis.

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A collagen membrane containing osteogenic protein-1 facilitates bone regeneration in a rat mandibular bone defect

Publication date: December 2017
Source:Archives of Oral Biology, Volume 84
Author(s): Manami Ozaki, Tadahiro Takayama, Takanobu Yamamoto, Yasumasa Ozawa, Mayu Nagao, Natsuko Tanabe, Akira Nakajima, Naoto Suzuki, Masao Maeno, Seiichi Yamano, Shuichi Sato
ObjectivesOsteogenic protein-1 (OP-1) has shown osteoinductive activities and is useful for clinical treatments, including bone regeneration. Regenerative procedures using a bioabsorbable collagen membrane (BCM) are well established in periodontal and implant dentistry. We evaluated the subsequent effects of the BCM in combination with OP-1 on bone regeneration in a rat mandibular circular critical-sized bone defect in vivo.DesignWe used 8 rats that received surgery in both sides of the mandible, and created the total 16 defects which were divided into 4 groups: Group 1; no treatment, as a control, Group 2; BCM alone, Group 3; BCM containing low dose 0.5μg of OP-1 (L-OP-1), and Group 4; BCM containing high dose 2.0μg of OP-1 (H-OP-1). Newly formed bone was evaluated by micro computed tomography (micro-CT) and histological analyses at 8 weeks postoperatively. In quantitative and qualitative micro-CT analyses of the volume of new bone formation, bone density, and percentage of new bone area was evaluated.ResultsBCM with rhOP-1 significantly increased and accelerated bone volume, bone mineral density, and percentage of new bone area compared to control and BCM alone at 8 weeks after surgery; these enhancements in bone regeneration in the OP-1-treated groups were dose-dependent.ConclusionsOP-1 delivered with a BCM may have effective osteoinductive potency and be a good combination for bone regeneration. The use of such a combination device for osteogenesis may result in safer and more predictable bone regenerative outcomes in the future.



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Un cas d’arthrite réactionnelle (syndrome oculo-urétro-synovial) traitée par infliximab

Publication date: Available online 19 September 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): K.-C. Ahogo, M. Bataille, A. Lasek, M. Wantz, D. Lebas, P. Modiano




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Vascularite cutanée induite par l’amiodarone

Publication date: Available online 19 September 2017
Source:Annales de Dermatologie et de Vénéréologie
Author(s): M. Ndiaye, B. Lebrun-Vignes, N. Ortonne, L. Fardet
IntroductionLes vascularites médicamenteuses peuvent être provoquées par une large variété de médicaments. Nous décrivons le cas d'un patient présentant une vascularite induite par l'amiodarone.ObservationUn homme de 57 ans rapportait un prurit d'apparition récente, rapidement associé à de larges plaques érythémateuses inflammatoires et nécrotiques des membres inférieurs et du dos. Ces lésions étaient apparues 6 semaines après l'introduction d'un traitement par amiodarone, prescrit pour des troubles du rythme supra-ventriculaires. Le diagnostic histologique (biopsie cutanée standard et immunofluorescence directe) était celui d'une vascularite avec présence de dépôts d'IgM et de C3 sur les vaisseaux. Le reste du bilan était sans particularité, notamment sans auto-anticorps ni cryoglobulinémie. Le patient imputait ses symptômes à l'introduction récente du traitement par amiodarone et l'arrêtait spontanément, sans avis médical. Aucun autre traitement n'était prescrit. Toutes les lésions, présentes depuis plus de 4 mois, disparaissaient alors rapidement et ne récidivaient pas (recul de 12 mois). Le diagnostic de vascularite médicamenteuse à l'amiodarone était retenu sur des critères d'imputabilité intrinsèque et extrinsèque compatibles et sur un recul de plusieurs mois sans récidive.DiscussionMoins de dix cas de vascularite induite par l'amiodarone sont disponibles dans la littérature médicale. On ne sait pas si cette entité est exceptionnelle, sous-diagnostiquée ou sous-rapportée.BackgroundA wide variety of drugs can cause cutaneous vasculitis. Herein we report a case of immune complex vasculitis induced by amiodarone.Patients and methodsA 57-year-old patient reported a recent history of pruritus associated with large erythematous, inflammatory, necrotic plaques localized on the lower limbs and back. These cutaneous lesions had appeared less than 2 months after initiation of amiodarone for supra-ventricular arrhythmia. Histological and direct immunofluorescence examinations of a skin biopsy sample revealed vasculitis with the presence of IgM and C3 immune complexes in vessels. The remaining laboratory tests were unremarkable (in particular, cryoglobulin and autoantibody tests were negative). The patient himself attributed his symptoms to the recent administration of amiodarone and spontaneously stopped the drug without medical advice. No other therapy was prescribed. Following drug withdrawal, the lesions that had been present for more than 4 months completely disappeared. No recurrence occurred after follow-up of over 6 months. The diagnosis of amiodarone-induced vasculitis was retained.DiscussionFewer than 10 cases of amiodarone-induced vasculitis have been reported in the medical literature. It is not known whether this entity is rare, under-diagnosed or under-reported.



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The Treatment of Actinic Keratoses—The Rule Rather Than the Exception—Reply

In Reply We would like to thank Mansouri and Housewright for engaging in a conversation that highlights (1) important questions about actinic keratosis (AK) and (2) principles about communication.

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Laser-Induced Neocollagenesis in Goltz Syndrome

This report describes treatment used to improve focal dermal hypoplasia by using ablative fractional laser resurfacing and characterizes the specific ratio of collagen types associated with observed clinical changes in a patient with Goltz syndrome.

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The Treatment of Actinic Keratoses—The Rule Rather Than the Exception

To the Editor We read with great interest the article by Berry et al entitled "Influence of Information Framing on Patient Decisions to Treat Actinic Keratosis." This work highlights a critical aspect of the physician-patient relationship—communication. As expected, the findings suggest that the verbiage used to describe actinic keratoses (AKs) can affect the patient's decision to pursue treatment. Interestingly, regardless of how the question was framed, most patients preferred to treat these lesions.

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Use of Telemedicine to Deliver Global Medical Care

By Nathan Douthit

Telemedicine is an important developing field for global health. Its use has been endorsed by the World Health Organization (WHO), Medecins Sans Frontieres and multiple other national health services and Non-Governmental Organizations (NGOs). Telemedicine has multiple definitions, but the one endorsed by the WHO is:

"The delivery of health care services, where distance is a critical factor, by all health care profes- sionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities". ¹

One of the earliest recorded instances of telemedicine was the transmission of an electrocardiograph in 1906. However, recent applications include sharing of data for specialist assistance in diagnosis and management, education of healthcare professionals and patients, research on difficult to reach populations and even screening services for health monitoring and maintenance. Telemedicine certainly has applications in the developed world and in urban centres. However, the effective delivery of telemedicine can make an unprecedented impact in developing countries and rural areas.

In the case report, "Remote care of a patient with stroke in rural Trinidad: use of telemedicine to optimize global neurological care," Reyes and Ramcharan describe "The use of… [telemedicine] for low-income countries to provide support for high-risk patients." Their case specifically focuses on the application of teleneurology, or remote access to specialists in neurology. The patient described was seen in hospital by a neurologist, but on discharge home it was noted that the "patient's home was located in a low income village 60 km away from the GP[general practitioner's] office." In order to continue monitoring the patient for improvement, the patient's 24 hour caregiver

"[W]as initially trained by the GP to collect, process and transmit the patient's data by the use of a smart phone and a laptop with internet access. The GP and the neurologist also used similar technology."

This allowed medical care to be provided to the patient in a timely fashion. The caregiver was educated to recognize seizures, falls, neurogenic bladder, and dysphasia.

"Once the event was recognised, the caregiver called on the GP assistance over a phone call and/or via email. The GP instructed the caregiver on first aid actions for the… event in order to prevent further complication… [and, if necessary, arranged] transportation of the patient to the nearest health facility available. Concurrently, the GP called on the senior neurologist for remote assistance…. The GP coordinated initial management of the complicated patient with the caregiver, paramedics and other doctors remotely…. The GP saw the patient directly to verify all instructions were carried out correctly, but there was no need for the neurologist to examine the patient for those reasons."

The authors conclude that this treatment model, "[S]uggest[s] that improved access to primary, secondary and tertiary levels of neurological care in remote and underserved regions of the world is a feasible way forward." They also correctly remind us that, "This is a global issue that requires urgent consensus and actions by stakeholders."

In light of this, BMJ Case Reports invites authors to publish cases regarding the trials and successes of telemedicine in delivering medicine in difficult to reach areas. Global health case reports can emphasize:

-successful models of management, such as the one above

-difficulties in implementing telemedicine due to cultural, geographical or technical constraints

-innovative uses of telemedicine

-the use of telemedicine across linguistic, cultural, ethnic and geopolitical barriers

Manuscripts may be submitted by students, physicians, nurses or other medical professionals to BMJ Case Reports. For more information, review the blog on how to write a global health case report.

 

Read more about telemedicine at BMJCR:

–Gestational trophoblastic disease in a Greenlandic Inuit: diagnosis and treatment in a remote area.

Selected References on telemedicine from other sources:

1. World Health Organization. Telemedicine: opportunities and developments in member states. Report on the second global survey on eHealth. World Health Organization:Geneva ; 2010.

-Medecins Sans Frontieres. MSF Telemedicine Brings Care to Patients in Remote Areas [Internet]. MSF USA: New York; 2016 June [cited Aug 10 2017]. Available from: http://ift.tt/28TJbTl

-Kasemsap K. The importance of telemedicine in global health care. InHandbook of research on healthcare administration and management 2017 (pp. 157-177). IGI Global.

-Silva BM, Rodrigues JJ, de la Torre Díez I, López-Coronado M, Saleem K. Mobile-health: A review of current state in 2015. Journal of biomedical informatics. 2015 Aug 31;56:265-72.

-Gornall J. Does telemedicine deserve the Green light? BMJ 2012;345:e4622.

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Economic Evaluation of Dupilumab for the Treatment of Moderate-to-Severe Atopic Dermatitis in Adults

Abstract

Introduction

Dupilumab significantly improves signs and symptoms of atopic dermatitis (AD), including pruritus, symptoms of anxiety and depression, and health-related quality of life versus placebo in adults with moderate-to-severe AD. Since the cost-effectiveness of dupilumab has not been evaluated, the objective of this analysis was to estimate a value-based price range in which dupilumab would be considered cost-effective compared with supportive care (SC) for treatment of moderate-to-severe AD in an adult population.

Methods

A health economic model was developed to evaluate from the US payer perspective the long-term costs and benefits of dupilumab treatment administered every other week (q2w). Dupilumab q2w was compared with SC; robustness of assumptions and results were tested using sensitivity and scenario analyses. Clinical data were derived from the dupilumab LIBERTY AD SOLO trials; healthcare use and cost data were from health insurance claims histories of adult patients with AD. The annual price of maintenance therapy with dupilumab to be considered cost-effective was estimated for decision thresholds of US$100,000 and $150,000 per quality-adjusted life-year (QALY) gained.

Results

In the base case, the annual maintenance price for dupilumab therapy to be considered cost-effective would be $28,770 at a $100,000 per QALY gained threshold, and $39,940 at a $150,000 threshold. Results were generally robust to parameter variations in one-way and probabilistic sensitivity analyses.

Conclusion

Dupilumab q2w compared with SC is cost-effective for the treatment of moderate-to-severe AD in US adults at an annual price of maintenance therapy in the range of $29,000–$40,000 at the $100,000–$150,000 per QALY thresholds.

Funding

Sanofi and Regeneron Pharmaceuticals, Inc.

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Different cochleovestibular manifestations and outcomes in patients diagnosed with dengue

Publication date: Available online 19 September 2017
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Isabella Marques Pereira Rahme, Geraldo Majela Pereira, Tanit Ganz Sanchez




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Assessing the potential role of next generation tyrosine kinase inhibitors in the treatment of cancers with acquired kinase domain mutations

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): A. Thirumal Raj, Shankargouda Patil, R. Ranadheer, R. Chandini




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Tumor thickness versus depth of invasion – Analysis of the 8th edition American Joint Committee on Cancer Staging for oral cancer

Publication date: November 2017
Source:Oral Oncology, Volume 74
Author(s): Richard Dirven, Ardalan Ebrahimi, Nikolaus Moeckelmann, Carsten Erich Palme, Ruta Gupta, Jonathan Clark
ObjectivesThe primary aim of this study is to compare the effect of using tumor thickness versus depth of invasion (DOI) to determine the 8th edition AJCC T-category on survival in a large cohort of OSCC.Materials and methodsA retrospective cohort study of patients whose clinicopathologic information had been collected prospectively into a dedicated head and neck database. 927 patients with oral SCC were identified in this cohort, with the final study population including 456 patients with complete information on DOI, tumor thickness, T and N staging and follow-up.Results26 (5.7%) patients had a different AJCC 8 T category when using thickness instead of depth. 15 were upstaged from T1 to T2, 10 upstaged from T2 to T3 and 1 down staged from T2 to T1. Additionally, similar stratification of disease-specific and overall survival curves were found for T category based on DOI and thickness.ConclusionThe T category and TNM stage prognostic performance of 8th edition AJCC staging of oral cancer is similar regardless of whether DOI or thickness is used as the T-category modifier.In centers without complete DOI data it is reasonable to impute thickness for retrospective survival analyses using the 8th edition of the AJCC staging system.



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Editorial Board/Aims & Scope

Publication date: October 2017
Source:Oral Oncology, Volume 73





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Current mouse models of oral squamous cell carcinoma: Genetic and chemically induced models

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): Kazuhisa Ishida, Hiroyuki Tomita, Takayuki Nakashima, Akihiro Hirata, Takauji Tanaka, Toshiyuki Shibata, Akira Hara
Oral squamous cell carcinoma (OSCC) patients have a low 5-year survival rate and poor prognosis. To improve survival and prognosis, the causes and processes involved in lesion development should be evaluated. For this purpose, the use of OSCC mouse models, such as chemically induced mouse models, genetically modified mouse models, and transplanted (xenograft) models, is crucial. These OSCC models exhibit both advantages and disadvantages when studying OSCC development and progression. Until a model resembling human OSCC is developed, both the advantages and disadvantages of each model should be carefully considered. In this review, we discuss OSCC mouse models and their use in cancer research worldwide.



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Chemoradiotherapy for locally advanced squamous cell carcinoma of the oropharynx: Does completion of systemic therapy affect outcomes?

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): Michael Baine, Tim Dorius, Nathan Bennion, Morshed Alam, Lynette Smith, Weining Zhen, Apar Ganti
IntroductionCurrent standard of care for locally advanced squamous cell carcinoma of the oropharynx (LA-OPC) consists of concurrent chemoradiotherapy. Due to toxicities associated with this treatment, a significant portion of patients are unable to complete the systemic therapy portion of their treatment course. The impact of incomplete systemic therapy on patient outcomes remains unclear.MethodsDemographic, treatment, and outcome data were retrospectively collected for patients with LA-OPC treated definitively with concurrent chemoradiotherapy between 2007 and 2014. Overall and disease-free survivals were estimated via the Kaplan Meier method. Log rank test was used to compare distributions of survival amongst groups. Cox regression was utilized for all multivariate analyses. P values of <0.05 were considered statistically significant.ResultsIn total, 73 patients with LA-OPC were identified with a median follow-up of 3.4years. Concurrent systemic therapy regimens consisted of bolus cisplatin every 3weeks (76.7%), weekly cetuximab (20.5%) and weekly cisplatin (2.7%). Forty-three patients (58.9%) were able to complete the prescribed concurrent systemic regimens. Upon multivariate analyses, patients who did not complete systemic therapy were noted to have a non-significant trend towards increased distant failure (20.0% vs 7.0%, p=0.12). Additionally, patients who did not complete systemic therapy were noted to have a near significant trend towards increased risk of death (36.7% vs 17.9%, p=0.053).ConclusionsThese results suggest that completing systemic therapy may affect survival in patients undergoing definitive radiotherapy with concurrent systemic therapy for LA-OPC. Further, this data demonstrates that though local recurrences are not affected when planned systemic therapy cycles are omitted, the risk of distant failure may increase. These associations require further study to clarify the effect Incomplete systemic therapy has on outcomes for LA-OPC.



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Poor oral health affects survival in head and neck cancer

Publication date: October 2017
Source:Oral Oncology, Volume 73
Author(s): Douglas R. Farquhar, Kimon Divaris, Angela L. Mazul, Mark C. Weissler, Jose P. Zevallos, Andrew F. Olshan
IntroductionPoor oral health has emerged as a risk factor for squamous cell carcinoma of the head and neck (HNSCC) but its impact on survival has not been examined. We sought to estimate the impact of oral health indicators on survival in a population-based HNSCC cohort.Materials and methodsCases (n=1381) and age-, sex- and race-matched controls (n=1396) were participants in the Carolina Head and Neck Cancer Epidemiologic Study (CHANCE). Vital status was determined via linkage with the National Death Index. Survival was considered at 5years post-diagnosis or study-enrollment for controls. Oral health was assessed using self-reported indicators including frequency of routine dental exams and tooth brushing. We used Kaplan-Meyer analyses and Cox regression to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI).ResultsRoutine dental visits during the preceding 10years were associated with decreased mortality risk (>10 visits: HR=0.6, 95% CI=0.4–0.8) after adjusting for confounders. This effect was most pronounced for oral cavity cancer—(e.g., >10 visits: HR=0.4, 95% CI=0.2–0.9). Dental visits were also positively associated with survival among controls. No other routine health screening (e.g., eye exams) was associated with survival.ConclusionWe found significant associations between markers of oral health and survival among both HNSCC cases and controls. This association was most pronounced for sites closer to the dentition. Oral health may have a direct effect on tumor biology due to the associated immune or inflammatory response. It may also represent a proxy for wellness or unmeasured social determinants of health.



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A Neonatal Case of Glial Choristoma of the Tongue Causing Airway Obstruction

Glial choristoma is considered to be a type of brain heterotopia consisting of ectopic central nervous tissue. We herein report a neonate with glial choristoma of the tongue who developed respiratory distress due to airway obstruction. A male neonate presented with respiratory distress due to a soft mass on the midline region of the dorsal tongue base at birth. He was intubated using a flexible fiberoptic nasopharyngoscope. MRI showed a well-circumscribed mass measuring 25 × 23 × 27 mm in size in the same region. A histologic examination confirmed a pathological diagnosis of glial choristoma. He underwent tracheotomy at 22 days of age, and a subtotal resection of the tumor was performed at five months of age. The clinical behavior of oral glial choristoma varies depending on the age at onset as well as the location and size of the mass. The small size of the organ and the narrow operating field hamper the surgical approach in neonates. The optimal therapeutic strategy for neonatal cases of glial choristoma should thus be determined based on the condition of each individual patient.

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Epithelial-Myoepithelial Carcinoma of the Base of Tongue with Possible Lung Metastases

Background. Epithelial-myoepithelial carcinomas are rare neoplasms usually arising from the salivary glands. There is limited evidence in the literature on their prognosis in the base of the tongue but other cases have resolved without recurrence. Methods. The patient underwent biopsies demonstrating the diagnosis of epithelial-myoepithelial carcinoma of the base of tongue and a PET scan showed multiple bilateral rounded pulmonary nodules. Results. The patient declined chemotherapy and radiotherapy to maximise his quality of life and passed away under management from palliative care several months later. Discussion. This is the only case in the literature of this type of carcinoma in the base of the tongue resulting in metastases and a poor prognosis. The case highlights the importance of checking for metastases in such lesions and their potentially serious outcomes if left untreated.

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Treatment outcomes of sialendoscopy for submandibular gland sialolithiasis: The minor axis of the sialolith is a regulative factor for the removal of sialoliths in the hilum of the submandibular gland using sialendoscopy alone

Publication date: Available online 19 September 2017
Source:Auris Nasus Larynx
Author(s): Norio Kondo, Toshio Yoshihara, Yukie Yamamura, Kaoru Kusama, Eri Sakitani, Yukako Seo, Mayako Tachikawa, Keiko Kujirai, Erika Ono, Yasuyo Maeda, Tomohito Nojima, Akiko Tamiya, Emiri Sato, Manabu Nonaka
ObjectiveTo assess the general guidelines for the removal of sialoliths for submandibular gland sialolithiasis using sialendoscopy alone.MethodsWe analyzed 61 sialoliths treated using sialendoscopy in 42 patients with submandibular gland sialolithiasis. We evaluated the submandibular gland sialoliths and divided each case based upon the location: the Wharton's duct or the hilum. We measured the major and minor axes of the sialoliths using a soft tissue computed-tomography (CT) scan and evaluated the removal rate of the sialoliths using sialendoscopy alone.ResultsThe removal rate of the sialoliths in the Wharton's duct (52.6%) was significantly higher than that in the hilum of the submandibular gland (26.1%) (P=0.042). The minor axis was significantly correlated to the treatment outcome of sialendoscopy alone for all cases (P=0.030). A significant correlation was observed for cases involving the hilum of the submandibular gland and the measurement of the minor axes of the sialoliths for the treatment outcome of sialendoscopy alone (P=0.009). The major axis showed no correlation with the treatment outcomes of sialendoscopy alone.ConclusionThe measurement of the minor axes of the sialoliths with a soft tissue CT scan was correlated with treatment outcome of sialendoscopy alone for all cases, particularly sialoliths in the hilum. The easurement of the major axis showed no correlation with outcomes of sialendoscopy alone.



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A targeted next-generation sequencing panel reveals novel mutations in Japanese patients with primary ciliary dyskinesia

Publication date: Available online 19 September 2017
Source:Auris Nasus Larynx
Author(s): Kazuhiko Takeuchi, Masako Kitano, Hiroko Kiyotoshi, Koji Ikegami, Satoru Ogawa, Makoto Ikejiri, Mizuho Nagao, Takao Fujisawa, Kaname Nakatani
ObjectivePrimary ciliary dyskinesia (PCD) is a rare genetic disorder caused by functional impairment of cilia throughout the body. The early diagnosis of PCD is important for the prevention of long-term sequelae; however, this is often challenging because of the phenotypic heterogeneity of PCD and difficulty in genetic analysis. The majority of PCD patients in Japan are not diagnosed properly. To diagnose PCD more accurately, we developed a targeted next-generation sequencing (NGS) panel.MethodsWe examined 46 patients (age range, 1–64 years; 23 male and 23 female) who were clinically suspected of PCD. First, mutation hotspots in DNAH5 and DNAI1 were sequenced by the Sanger method. Next, exome sequencing was performed in 32 known PCD genes using our novel NGS panel with the Ion Torrent PGM system. Variant annotation was generated by Ion Reporter Version 5.0 (Life Technologies). Mutations found in the panel were validated by Sanger sequencing.ResultsDisease-causing gene mutations were found in 10 patients from 7 families: DNAH5 in 4 families, and DNAI1, CCDC40, and RSPH4A in 1 family each. Heterozygous mutations were found in 1 patient. The majority of the mutations found in the present analysis were novel.ConclusionJapanese PCD patients have novel mutations in cilia-related genes. This targeted NGS panel can identify disease-causing mutations in patients with PCD.



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Protease-Activated Receptor-2 blockade inhibits changes seen in a chronic murine asthma model

Abstract

Proteinase-Activated Receptor-2 (PAR₂) is a G protein-coupled receptor activated by serine proteinases. We have shown that PAR₂ activation in the airways is involved in the development of allergic inflammation and airway hyperresponsiveness (AHR) in acute murine models. We hypothesize that functional inhibition of PAR₂ prevents allergic inflammation, AHR and airway remodeling in chronic allergic airway inflammation models. We developed a 12 week model of cockroach extract (CE)-mediated AHR, airway inflammation and remodeling in BALB/c. These mice exhibit AHR, increased numbers of eosinophils in bronchoalveolar lavage (BAL) and increased collagen content in the lung tissue compared to saline controls. Administration of an anti-PAR₂ antibody, SAM-11, after the initial development of airway inflammation significantly inhibited all these parameters. Our data demonstrate that PAR₂ signaling plays a key role in CE-induced AHR and airway inflammation/remodeling and that targeting PAR₂ activation may be a successful therapeutic strategy for allergic asthma.

This article is protected by copyright. All rights reserved.

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Serine protease allergen favours Th2 responses via PAR-2 and STAT-3 activation in murine model

Abstract

Background

Protease activity of Per a 10 favours Th2 responses by differential regulation of IL-12p70 and IL-23 cytokine subunits. The present study aims to elucidate the underlying mechanism of differential regulation of IL-12p70 and IL-23.

Methods

PAR-2 activation was blocked in murine model by administering SAM11 before each sensitization. CD11c⁺ p-STAT3⁺ cells were measured in lungs by flow cytometry. BMDCs were pre-treated with SAM-11 or isotype control or stattic and stimulated with Per a 10. p-STAT3 levels were measured using Western blot. Transcript levels of IL-12p35, IL12/23p40 and IL-23p19 were measured using RT PCR. Cytokine levels were analysed using ELISA.

Results

Protease activity of Per a 10 increases p-STAT3 levels in mice lungs, which gets reduced on PAR-2 blockage. Percentage of p-STAT3⁺ CD11c⁺ cells was higher in Per a 10 administered mice and gets reduced upon PAR-2 blockage. IL-12p35 and IL-12p70 levels were higher, IL-23p19 and IL-23 levels were lower in both SAM-11 treated mice and BMDCs indicating a role of PAR-2 mediated signalling. IL-4, TSLP, IL-17A, EPO activity, total cell count and specific IgE and IgG1 levels were lower in SAM-11 administered mice. Inhibiting STAT3 activation via stattic also leads to lower levels of IL-23p19, IL-23 and higher level of IL-12p35.

Conclusions

Per a 10 leads to PAR-2 activation on BMDCs resulting in downstream activation of STAT3 to regulate the balance between IL-12/IL-23 subunits causing a cytokine milieu rich in IL-23 to favour Th2 polarization.

This article is protected by copyright. All rights reserved.

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Erratum to: Human Immune Monitoring Techniques during Food Allergen Immunotherapy

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TLR7/8 agonists stimulate plasmacytoid dendritic cells to initiate a Th17-deviated acute contact dermatitis in humans

Publication date: Available online 19 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): Natalie Garzorz-Stark, Felix Lauffer, Linda Krause, Jenny Thomas, Anne Atenhan, Regina Franz, Sophie Roenneberg, Alexander Boehner, Manja Jargosch, Richa Batra, Nikola S. Mueller, Stefan Haak, Christina Groß, Olaf Groß, Claudia Traidl-Hoffmann, Fabian J. Theis, Carsten B. Schmidt-Weber, Tilo Biedermann, Stefanie Eyerich, Kilian Eyerich
BackgroundA standardized human model to study early pathogenic events in psoriasis is missing. Activation of Toll-like receptor 7/8 by topical application of imiquimod is the most commonly used mouse model of psoriasis.ObjectiveTo investigate the potential of a human imiquimod patch test model to resemble human psoriasis.MethodsImiquimod (Aldara® 5% cream) was applied twice a week onto the back of volunteers (n=18) and the development of skin lesions was monitored over a time period of four weeks. Consecutive biopsies were taken for whole genome expression analysis, histology and T cell isolation. pDC were isolated from whole blood, stimulated with TLR7 agonist and analysed by extracellular flux analysis and real time PCR.ResultsWe demonstrate imiquimod induces a monomorphic and self-limited inflammatory response in healthy individuals as well as psoriasis or eczema patients, respectively. The clinical and histologic phenotype as well as transcriptome of imiquimod-induced inflammation in human skin resembles an acute contact dermatitis rather than psoriasis. Nevertheless, the imiquimod model mimics hallmarks of psoriasis. Namely, plasmacytoid dendritic cells (pDC) are primary sensors of imiquimod, responding with production of pro-inflammatory and Th17-skewing cytokines. This results in a Th17 immune response with IL-23 as a key driver. In a proof-of-concept setting, systemic treatment with ustekinumab diminished the imiquimod-induced inflammation.ConclusionIn humans, imiquimod induces contact dermatitis with the distinctive feature that pDC are the primary sensors, leading to an IL-23/Th17 deviation. Despite these shortcomings, the human imiquimod model might be useful to investigate early pathogenic events and prove molecular concepts in psoriasis.

Teaser

Stimulation of TLR7/8 in human skin induces an acute contact dermatitis with pDC as primary sensors and IL-23 as essential driver of the reaction, thus constituting a standardized, but limited model of human psoriasis.


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Early-life home environment and risk of asthma among inner-city children

Publication date: Available online 19 September 2017
Source:Journal of Allergy and Clinical Immunology
Author(s): George T. O'Connor, Susan V. Lynch, Gordon R. Bloomberg, Meyer Kattan, Robert A. Wood, Peter J. Gergen, Katy F. Jaffee, Agustin Calatroni, Leonard B. Bacharier, Avrahman Beigelman, Megan T. Sandel, Christine C. Johnson, Ali Faruqi, Clark Santee, Kei E. Fujimura, Douglas Fadrosh, Homer Boushey, Cynthia M. Visness, James E. Gern
BackgroundEnvironmental exposures in early life appear to play an important role in the pathogenesis of childhood asthma, but the potentially modifiable exposures that lead to asthma remain uncertain.ObjectiveWe sought to identify early-life environmental risk factors for childhood asthma in a birth cohort of high-risk inner-city children.MethodsWe examined the relationship of prenatal and early-life environmental factors to the occurrence of asthma at 7 years of age among 442 children.ResultsHigher house dust concentrations of cockroach, mouse, and cat allergens in the first 3 years of life were associated with lower risk of asthma (for cockroach allergen: odds ratio per interquartile range increase in concentration, 0.55; 95% CI, 0.36-0.86; P < .01). House dust microbiome analysis using 16S ribosomal RNA sequencing identified 202 and 171 bacterial taxa that were significantly (false discovery rate < 0.05) more or less abundant, respectively, in the homes of children with asthma. A majority of these bacteria were significantly correlated with 1 of more allergen concentrations. Other factors associated significantly positively with asthma included umbilical cord plasma cotinine concentration (odds ratio per geometric SD increase in concentration, 1.76; 95% CI, 1.00-3.09; P = .048) and maternal stress and depression scores.ConclusionAmong high-risk inner-city children, higher indoor levels of pet or pest allergens in infancy were associated with lower risk of asthma. The abundance of a number of bacterial taxa in house dust was associated with increased or decreased asthma risk. Prenatal tobacco smoke exposure and higher maternal stress and depression scores in early life were associated with increased asthma risk.



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Routine pathologic examination of tonsillectomy specimens: A 10-year experience at a tertiary care children's hospital

Publication date: November 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 102
Author(s): Jamie Glancy Bizzell, Gresham T. Richter, Charles M. Bower, Gail L. Woods, Abby R. Nolder
ObjectiveTo review histopathologic diagnoses from tonsillectomy specimens and determine whether routine pathologic exam is necessary.MethodsPathology reports of patients undergoing tonsillectomy from 2005 to 2014 at our pediatric tertiary care hospital were reviewed. Histopathologic diagnoses were recorded with special attention to identification of malignancy.ResultsA total of 8807 paired tonsil specimens were sent to pathology over a 10-year course. Gross analysis was performed on all. Microscopic histopathologic analysis was performed on 612 (6.95%) specimens with all but one demonstrating strictly reactive lymphoid hyperplasia. The single specimen (0.16%) demonstrated follicular hyperplasia with focal necrotizing granulomatous lymphadenitis without organisms identified on special staining. The surgeon requested pathologic diagnosis to rule out lymphoma in 4 of 8087 (0.05%) of the specimens. No malignancies were identified. The approximate charges for gross examination of a paired tonsillectomy specimen and microscopic examination were $136.10 and $294.54, respectively. Over the 10 year period of the study, total charges were estimated at $1,115,340 (gross) and $180,258 (microscopic).DiscussionMicroscopic analysis of tonsil specimens is unlikely to identify abnormal pathology that changes patient management. This study suggests that neither gross nor microscopic pathologic examination of tonsillectomy specimens is necessary on a routine basis. Histologic analysis of tonsils should be requested only on a case by case basis when clinical suspicion for malignancy is high. Avoiding routine pathologic exam of tonsils may be cost effective and medically safe.



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Impact of socioeconomic factors on paediatric cochlear implant outcomes

Publication date: November 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 102
Author(s): Shalabh Sharma, Khyati Bhatia, Satinder Singh, Asish Kumar Lahiri, Asha Aggarwal
ObjectivesThe study was aimed at evaluating the impact of certain socioeconomic factors such as family income, level of parents' education, distance between the child's home and auditory verbal therapy clinic, and age of the child at implantation on postoperative cochlear implant outcomes.MethodsChildren suffering from congenital bilateral profound sensorineural hearing loss and a chronologic age of 4 years or younger at the time of implantation were included in the study. Children who were able to complete a prescribed period of a 1-year follow-up were included in the study. These children underwent cochlear implantation surgery, and their postoperative outcomes were measured and documented using categories of auditory perception (CAP), meaningful auditory integration (MAIS), and speech intelligibility rating (SIR) scores. Children were divided into three groups based on the level of parental education, family income, and distance of their home from the rehabilitation-- auditory verbal therapy clinic.ResultsA total of 180 children were studied. The age at implantation had a significant impact on the postoperative outcomes, with an inverse correlation. The younger the child's age at the time of implantation, the better were the postoperative outcomes. However, there were no significant differences among the CAP, MAIS, and SIR scores and each of the three subgroups. Children from families with an annual income of less than $7,500, between $7,500 and $15,000, and more than $15,000 performed equally well, except for significantly higher SIR scores in children with family incomes more than $15,000. Children with of parents who had attended high school or possessed a bachelor's or Master's master's degree had similar scores, with no significant difference. Also, distance from the auditory verbal therapy clinic failed to have any significantimpact on a child's performance.DiscussionThese results have been variable, similar to those of previously published studies. A few of the earlier studies concurred with our results, but most of the studies had suggested that children in families of higher socioeconomic status had have better speech and language acquisition.ConclusionsCochlear implantation significantly improves auditory perception and speech intelligibility of children suffering from profound sensorineural hearing loss. Younger The younger the age at implantation, the better are the results. Hence, early implantation should be promoted and encouraged. Our study suggests that children who followed the designated program of postoperative mapping and auditory verbal therapy for a minimum period of 1 year seemed to do equally well in terms of hearing perception and speech intelligibility, irrespective of the socioeconomic status of the family. Further studies are essential to assess the impact of these factors on long-term speech acquisition andlanguage development.



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Transient Ischemic Attack and Ischemic Stroke in Danon Disease with Formation of Left Ventricular Apical Thrombus despite Normal Systolic Function

Danon disease is a rare X-linked dominant skeletal and cardiac muscle disorder presenting with hypertrophic cardiomyopathy, Wolf-Parkinson-White syndrome, skeletal myopathy, and mild intellectual disability. Early morbidity and mortality due to heart failure or sudden death are known in Danon disease, more in males than in females. Here, we present a 17-year-old female adolescent with Danon disease and severe concentric hypertrophy with normal left ventricular (LV) systolic function, who has been complaining of intermittent headache and weakness for about 3 years, initially diagnosed with hemiplegic migraine. Subsequently, her neurological manifestation progressed to transient ischemic attack (TIA) and eventually to ischemic stroke confirmed by CT scan with 1-day history of expressive aphasia followed by persistent left side weakness and numbness. Detailed echocardiogram for the first time revealed a small LV apical thrombus with unchanged severe biventricular hypertrophy and normal systolic function. This unexpected LV apical thrombus may be associated with a wide spectrum of neurological deficits ranging from TIA to ischemic stroke in Danon disease. Possibility of cerebral ischemic events should be suspected in Danon disease when presenting with neurological deficits even with normal systolic function. Careful assessment for LV apical thrombus is warranted in such cases.

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Successful treatment of trichoepithelioma with a novel insulated, monopolar, radiofrequency microneedle device

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Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial

Objectives/Hypothesis

To assess balloon dilation of the Eustachian tube with Eustachian tube balloon catheter in conjunction with medical management as treatment for Eustachian tube dilatory dysfunction.

Study Design

In this prospective, multicenter, randomized, controlled trial, we assigned, in a 2:1 ratio, patients age 22 years and older with Eustachian tube dilatory dysfunction refractory to medical therapy to undergo balloon dilation of the Eustachian tube with balloon catheter in conjunction with medical management or medical management alone.

Methods

The primary endpoint was normalization of tympanogram at 6 weeks. Additional endpoints were normalization of Eustachian Tube Dysfunction Questionaire-7 symptom scores, positive Valsalva maneuver, mucosal inflammation, and safety.

Results

Primary efficacy results demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone. Tympanogram normalization at 6-week follow-up was observed in 51.8% (72/139) of investigational patients versus 13.9% (10/72) of controls (P < .0001). Tympanogram normalization in the treatment group was 62.2% after 24 weeks. Normalization of Eustachian Tube Dysfunction Questionaire-7 Symptom scores at 6-week follow-up was observed in 56.2% (77/137) of investigational patients versus 8.5% (6/71) controls (P < .001). The investigational group also demonstrated substantial improvement in both mucosal inflammation and Valsalva maneuver at 6-week follow-up compared to controls. No device- or procedure-related serious adverse events were reported for those who underwent balloon dilation of the Eustachian tube.

Conclusions

This study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter + medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults.

Level of evidence

1b Laryngoscope, 2017

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Folliculocentric hyperkeratotic lichen sclerosus in a 7-year-old child successfully treated with narrowband ultraviolet B phototherapy

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Promotion of early pediatric hearing detection through patient navigation: A randomized controlled clinical trial

Objectives/Hypothesis

To assess the efficacy of a patient navigator intervention to decrease nonadherence to obtain audiological testing following failed screening, compared to those receiving the standard of care.

Methods

Using a randomized controlled design, guardian-infant dyads, in which the infants had abnormal newborn hearing screening, were recruited within the first week after birth. All participants were referred for definitive audiological diagnostic testing. Dyads were randomized into a patient navigator study arm or standard of care arm. The primary outcome was the percentage of patients with follow-up nonadherence to obtain diagnostic testing. Secondary outcomes were parental knowledge of infant hearing testing recommendations and barriers in obtaining follow-up testing.

Results

Sixty-one dyads were enrolled in the study (patient navigator arm = 27, standard of care arm = 34). The percentage of participants nonadherent to diagnostic follow-up during the first 6 months after birth was significantly lower in the patient navigator arm compared with the standard of care arm (7.4% vs. 38.2%) (P = .005). The timing of initial follow-up was significantly lower in the navigator arm compared with the standard of care arm (67.9 days after birth vs. 105.9 days, P = .010). Patient navigation increased baseline knowledge regarding infant hearing loss diagnosis recommendations compared with the standard of care (P = .004).

Conclusions

Patient navigation decreases nonadherence rates following abnormal infant hearing screening and improves knowledge of follow-up recommendations. This intervention has the potential to improve the timeliness of delivery of infant hearing healthcare; future research is needed to assess the cost and feasibility of larger scale implementation.

Level of Evidence

1b Laryngoscope, 2017

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Fever, lipodystrophy and cutaneous lesions

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Urban and rural differences in outcomes of head and neck cancer

Objectives/Hypothesis

To assess for potential urban and rural disparities in head and neck cancer (HNC) outcomes within a single-payer healthcare system.

Study Design

A large retrospective population-based cohort analysis of consecutive HNC patients treated in British Columbia, Canada between 2001 and 2010 was conducted.

Methods

All patients diagnosed with HNC from 2001 to 2010 and referred to any one of five British Columbia Cancer Agency centers for management were reviewed. Based on census data, patients were classified into: 1) rural, 2) small urban, 3) moderate urban, and 4) large urban areas. Kaplan-Meier methods and Cox regression models were used to correlate site of residence with overall survival (OS), controlling for prognostic factors that included sociodemographic and other tumor and treatment-related characteristics.

Results

We identified 3,036 patients; the median age was 64 years, 26% were women, and 32% had Eastern Cooperative Oncology Group (ECOG) 0 or 1. The majority resided in large urban areas (55%) followed by rural (22%), moderate urban (13%), and small urban (10%). In regression analyses, smoking (hazard ratio [HR]: 2.10, 95% confidence interval [CI]: 1.28-3.45, P < .001), ECOG 2 + (HR: 3.44, 95% CI: 2.26-5.22, P < .001), oral cavity (HR: 1.54, 95% CI: 1.03-2.32, P = .04) and hypopharyngeal tumors (HR: 2.31, 95% CI: 1.42-3.77, P = .00), and large tumor size (HR: 1.69, 95% CI: 1.08-2.64, P = .02) were correlated with inferior OS, but site of residence was not. When stratified by type of treatment, OS remained similar irrespective of urban or rural residence.

Conclusions

Urban–rural differences in HNC survival outcomes were not observed.

Level of Evidence

2c Laryngoscope, 2017

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Serum IL-17 in patients with erythema multiforme or Stevens–Johnson syndrome/toxic epidermal necrolysis drug reaction, and correlation with disease severity

Summary

Background

There is strong evidence that drug-induced cutaneous eruptions have an immunological component. Interleukin (IL)-17, a proinflammatory cytokine that is predominantly produced by T helper 17 cells, has been linked to various autoimmune and inflammatory diseases.

Aim

To measure serum IL-17 levels in patients with cutaneous drug reactions [erythema multiforme (EM) and Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN)] in order to study the associations between IL-17 and disease severity.

Methods

In total, 32 patients (13 with EM and 19 with SJS/TEN) and 15 age- and sex-matched healthy controls (HCs) were enrolled. Patients with SJS/TEN were assessed clinically using the SCORe of Toxic Epidermal Necrosis (SCORTEN) scale. Serum IL-17 levels were determined by ELISA.

Results

Serum IL-17 levels were significantly higher compared with HCs (16.46 ± 5.21 pg/mL) in the EM (35.1 ± 23.89 pg/mL, P < 0.02) and SJS/TEN (68.19 ± 35.42 pg/mL, P = 0.001) groups. IL-17 levels were also significantly higher in the SJS/TEN group than in the EM group (P = 0.004). Mean affected body surface area percentage was 0.9 ± 0.21 in the EM group and 22.8 ± 10.67 in the SJS/TEN group. The SJS/TEN SCORTEN ranged from 1 to 5, with a mean of 2.5 ± 1. Serum IL-17 level correlated positively with both percentage surface area of detached skin and SCORTEN.

Conclusions

Serum IL-17 levels may have prognostic and diagnostic value in patients with EM or SJS/TEN reactions, and can provide a valuable approach in managment.

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Inducible T-cell costimulator (ICOS) and CD28 polymorphisms possibly play a role in the pathogenesis of chronic autoreactive urticaria

Summary

Background

Clinical experience emphasizes the coexistence of chronic spontaneous urticaria (CSU) and autoimmune disturbances. In chromosome 2q33-34, there is a cluster of homologous genes that are considered promising candidate genes for susceptibility to autoimmune diseases.

Aim

To examine the possible role of polymorphisms in the genes for CD28 and inducible T-cell costimulator (ICOS) in the background of CSU.

Methods

In total, 149 patients with CSU with positive autologous serum skin test were enrolled in the study. The healthy control (HC) group consisted of 100 healthy volunteers. In all subjects, the CD28 rs2140148 and rs3116496 and the ICOS rs6726035 polymorphisms were analysed. Disease severity was assessed by means of Urticaria Activity Score.

Results

We found a statistically significantly lower prevalence of the ICOS rs6726035 TT genotype among patients with CSU compared with HCs. Furthermore, the haplotype rs2140148A, rs3116496T and rs6726035C presented a possible association with CSU. We did not find any association between the examined polymorphisms and either urticaria severity or age of disease onset.

Conclusions

Our results underline the role of autoimmune components in the pathogenesis of chronic autoreactive urticaria, and indicate it as a potentially genetically related disorder.

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The folded postauricular flap: A novel approach to reconstruction of large full thickness defects of the conchal bowl

Publication date: Available online 19 September 2017
Source:American Journal of Otolaryngology
Author(s): Ansley M. Roche, Martha Griffin, Ron Shelton, Mark L. Urken
Extensive subtotal full-thickness auriculectomy defects pose a challenge for the reconstructive surgeon. The posterior island flap (PIF), based on the posterior auricular artery, has been described as a reconstructive option for auricular defects, with reports describing a "pull-through" or "revolving door" technique to reconstruct subtotal partial thickness and full thickness auricular defects. These techniques may result in posterior "pinning" of the auricle. This patient is an 87-year-old male who presented after Mohs excision of squamous cell carcinoma of the conchal bowl, which resulted in a 4x4cm subtotal auriculectomy defect. A folded PIF was used to reconstruct the large full thickness defect, in a multistage manor. Post-operatively, the patient had a reconstructed auricle that was suitable for wearing hearing aids and glasses. We describe a novel technique of the folded PIF for an extensive full-thickness auricular defect, which utilizes a single, well camouflaged donor site, provides well-vascularized local tissue with excellent color match, and allows for the restoration of the post-auricular sulcus.



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Comparison of radiation doses imparted during 128-multislice CT-scanners and cone beam computed tomography for intra- and perioperative cochlear implant assessment

Publication date: Available online 19 September 2017
Source:American Journal of Otolaryngology
Author(s): N. Guberina, U. Dietrich, D. Arweiler-Harbeck, M. Forsting, A. Ringelstein
PurposeTo examine radiation-doses imparted during multislice (MSCT) and cone-beam computed-tomography (CBCT) for perioperative examination of cochlear-implant insertion.MethodsRadiation-doses were assessed during standardized petrous-bone CT-protocols at different MSCT ((I) single-source CT-scanner Somatom-Definition-AS+, (II) 2nd generation of dual-source CT-scanner Somatom-Definition-Flash, (III) 3rd generation of dual-source CT-scanner Somatom-Force and at the CBCT Ziehm-Vision-RFD3D ((IV) (a) RFD-3D (Standard-modifier), (b) RFD-3D (Low-dose-modifier)). Image quality was examined by two radiologists appraising electrode-array placement, quality-control of cochlear-implant surgery and complications based on real patients' examinations (n=78).ResultsIn MSCT-setting following radiation-doses were assessed (CTDIw; DLP): (I) 21.5mGy; 216mGycm; (II) 19.7mGy; 195mGycm; (III) 12.7mGy; 127mGycm; in the CBCT setting radiation doses were distributed as follows: (IV) (a) 1.9mGy; 19.4mGycm; (b) 1.2mGy; 12.9mGycm. Overall, image quality was evaluated as good for both, MSCT- and CBCT-examinations, with a good interrater reliability (r=0.81).ConclusionCBCT bears considerable dose-saving potential for the perioperative examination of cochlear-implant insertion while maintaining adequate image quality.



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Marital status as a predictor of survival in patients with human papilloma virus-positive oropharyngeal cancer

Publication date: Available online 19 September 2017
Source:American Journal of Otolaryngology
Author(s): Samuel J. Rubin, Diana N. Kirke, Waleed H. Eazzat, Minh T. Truong, Andrew R. Salama, Scharukh Jalisi
PurposeDetermine whether marital status is a significant predictor of survival in human papillomavirus-positive oropharyngeal cancer.Materials and methodsA single center retrospective study included patients diagnosed with human papilloma virus-positive oropharyngeal cancer at Boston Medical Center between January 1, 2010 and December 30, 2015, and initiated treatment with curative intent at Boston Medical Center. Demographic data and tumor-related variables were recorded. Univariate analysis was performed using a two-sample t-test, chi-squared test, Fisher's exact test, and Kaplan Meier curves with a log rank test. Multivariate survival analysis was performed using a Cox regression model.ResultsA total of 65 patients were included in the study with 24 patients described as married and 41 patients described as single. There was no significant difference in most demographic variables or tumor related variables between the two study groups, except single patients were significantly more likely to have government insurance (p=0.0431). Furthermore, there was no significant difference in 3-year overall survival between married patients and single patients (married=91.67% vs single=87.80%; p=0.6532) or 3-year progression free survival (married=79.17% vs single=85.37%; p=0.8136). After adjusting for confounders including age, sex, race, insurance type, smoking status, treatment, and AJCC combined pathologic stage, marital status was not a significant predictor of survival [HR=0.903; 95% CI (0.126,6.489); p=0.9192].ConclusionsAlthough previous literature has demonstrated that married patients with head and neck cancer have a survival benefit compared to single patients with head and neck cancer, we were unable to demonstrate the same survival benefit in a cohort of patients with human papilloma virus-positive oropharyngeal cancer.



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Neonatal BCG-vaccination and atopic dermatitis before 13 months of age. A randomised clinical trial

Abstract

Studies have suggested that Bacillus Calmette-Guérin (BCG) vaccination may reduce the risk of allergic diseases, including atopic dermatitis.

The Danish Calmette Study was conducted 2012-2015. Within 7 days of birth new-borns were randomised 1:1 to BCG or no BCG. Exclusion criteria were gestational age <32 weeks, birth weight <1000 g, known immunodeficiency or no Danish-speaking parent. Data were collected through telephone interviews and clinical examinations until 13 months.

Clinical atopic dermatitis was diagnosed in 466/2,052 (22.7%) children in the BCG group and 495/1,952 (25.4%) children in the control group (RR=0.90 (95% confidence intervals 0.80 to 1.00)). The effect of neonatal BCG vaccination differed significantly between children with atopic predisposition (RR 0.84 (0.74 to 0.95)) and children without atopic predisposition (RR 1.09 (0.88 to 1.37)) (test of no interaction, p=0.04).

Among children with atopic predisposition, the number-needed-to-treat with BCG to prevent one case of atopic dermatitis was 21 (12 to 76).

This article is protected by copyright. All rights reserved.

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