Otolaryngology–Head and Neck Surgery

OBJECTIVES: The goal of this study was to evaluate the accuracy of the registration process and to identify potential sources of error during anterior cranial base surgery.

STUDY DESIGN AND SETTING: The registration accuracy of image guidance and the location of excluded fiducials were recorded prospectively from 50 endoscopic, anterior cranial base procedures in an academic university setting.

RESULTS: The mean error of initial registration was 2.8 mm (range, 1.4 to 7.1 mm). Following the exclusion of fiducials the mean error of registration was 1.6 mm (range, 0.6 to 3.7 mm). There was a significant improvement in the mean error rate from initial to final registration following the exclusion of fiducials (P < 0.0001). Posterior fiducials were excluded most often and anterior fiducials were excluded the least. Registration accuracy was similar for CT and MRI (P = 0.64).

CONCLUSIONS: The accuracy of the Stryker Image Guidance System is enhanced by the exclusion of individual fiducials with high registration errors.

SIGNIFICANCE: The exclusion of fiducials with high registration errors increases the accuracy of image guidance in anterior cranial base surgery.

OBJECTIVES: To evaluate the impact of image-guidance technology on intraoperative complications during frontal sinus obliteration surgery.

STUDY DESIGN AND SETTING: Retrospective case control. Twenty-four patients underwent frontal sinus obliteration with image-guidance technology (n = 15) or conventional instrumentation (n = 9) between 1992 and 2003. The image-guidance system was used to delineate the frontal sinus perimeter and direct cuts through the frontal bone.

RESULTS: Intraoperative complications occurred in none of the patients in the image-guidance group and in 3 patients in the control group (P = 0.042). Adverse events included dural tear with CSF leak in 2 patients and exposure of orbital fat in 1 patient. The incidence of postoperative complications was similar between groups (P = 0.326). No patients required revision surgery. Mean follow-up was 5.2 years.

CONCLUSIONS: The use of surgical navigation during frontal sinus obliteration appears to improve intraoperative safety.

SIGNIFICANCE: This is the first report to document a reduction in the rate of intraoperative complications when image guidance is utilized for frontal sinus surgery.

OBJECTIVES: The FrameLock (FL) is a bone anchored, reference arc fixation device for image guided surgery. This study compares the stability of the FL to the FESS frame (FF), a friction fit device.

METHODS: The FL and FF were independently applied to a cadaver. Fifteen sequentially larger impulse forces were applied to each device (0.39–5.8 N*s). Following each impulse, anatomic drift was recorded. A 29 patient prospective clinical trial tested the accuracy of each device before and after surgery.

RESULTS: The FL showed significantly less anatomic drift for all weights except 0.39 N*s (P < 0.01). The average clinical displacement of the FL was 0.07 mm, and of the FF was 1.02 mm (P < 0.0009). Linear regression analysis of anatomic drift as a function of the procedure duration revealed a positive correlation for the FF (y = 0.61x), but not for the FL (y = 0.02x).

CONCLUSIONS: The bone anchored FL is significantly more stable than the friction fit FF.

OBJECTIVE: Describe frontal sinus pneumatization in patients with no history of frontal sinus disease.

STUDY DESIGN AND METHODS: All 1-mm axial sinus CT scans performed from 2001 through 2003 were eligible for review on a CBYON Suite workstation (CBYON, Mountain View, CA). Exclusion criteria included frontal sinusitis, sinonasal polyposis, age < 18 years, sinus malignancy, fibroosseous lesions, maxillofacial trauma, congenital anomaly, and sinus surgery.

RESULTS: A total of 50 patients met the inclusion criteria. The prevalence of each structure was: agger nasi cell (89%), type 1 frontal cell (37%), type 2 frontal cell (19%), type 3 frontal cell (8%), type 4 frontal cell (0%), supraorbital ethmoid cell (62%), suprabullar cell (15%), frontal bullar cell (9%), interfrontal septal cell (14%), and recessus terminalis (22%).

CONCLUSIONS: This study describes frontal pneumatization in patients without a history of conditions that influence frontal pneumatization. The results characterize normal frontal recess/sinus pneumatization patterns.

OBJECTIVE: To evaluate the success of endoscopic and endoscope-assisted resection of inverted sinonasal papillomas and to assess the indications for adjunctive external procedures.

STUDY DESIGN: Retrospective chart review.

RESULTS: Fifty patients were treated surgically during the 10-year study period and had greater than 1 year of follow-up care. These patients had a recurrence rate of 14% (7/50) with a mean follow-up of 31.1 months. Of these 7 patients with recurrences, 3 were treated primarily at this institution, and 4 had been treated prior to referral. Recurrence was 11% (3/27) for primary resections and 17% (4/23) for secondary resections. Average time to recurrence was 11.7 months. Of the patients, 38% (19/50) had adjunctive external procedures either during the initial resection or for the management of recurrent disease.

CONCLUSIONS: Endoscopic and endoscope-assisted resections of inverted papilloma are effective techniques for managing inverted papilloma. The intraoperative findings, most importantly the site(s) of tumor attachment, dictate whether an endoscopic procedure is sufficient to complete resect the inverted papilloma or whether an adjunctive external procedure is required. Appropriate patient selection and an aggressive surgical approach are necessary for the management of these neoplasms.

OBJECTIVE: The endoscopic approach can be successfully employed for the treatment of benign tumors such as fibroosseus and vascular lesions, pleomorphic adenomas, gliomas, and schwannomas.

STUDY DESIGN AND SETTING: Nineteen patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were retrospectively reviewed. The endoscopic approach was used exclusively in 15 cases and was associated with an external approach in 4 cases (due to an intracranial extension of the tumor in 3 patients and its location at the level of the anterior wall of the frontal sinus in the last case).

RESULTS: The resection of the lesions was radical in 18 patients and subtotal in 1 case. The mean follow-up was 27 months and only 1 recurrence (5%) was observed in the juvenile angiofibroma group 20 months postoperatively.

CONCLUSION AND SIGNIFICANCE: In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

OBJECTIVE: Endonasal extended frontal sinusotomy is needed in rare cases of therapy-resistant chronic frontal sinusitis. Several types of burs have been invented to ablate strong bone in the frontal sinus access but nevertheless surgical results seem to differ significantly. The benefits and shortcomings of different burs are subjected to a comparative evaluation.

STUDY DESIGN: Five cadaver specimens were duplicated by means of dental molding and casting techniques to provide identical microanatomy for comparative studies on frontal sinusotomy. Different burs (conventional straight bur, right-angled bur according to Blokmanis, and curved frontal sinusbur) were applied to create a type IIb frontal sinusotomy according to Draf in microanatomical replicas. The geometry of the frontonasal neoostium was measured and its dimensions were contrasted to the collateral damage. Bone ablation was calculated by repeated weighting and the area of damaged mucosa was quantified using a 3D analyzing system.

RESULTS: A frontal sinus neoostium measuring 9 × 10 mm on average was created by type IIb frontal sinusotomy according to Draf. The complementary use of an angled bur showed some specific improvements that applied best to spacious anatomic specimens. Those specimens subjected to an extensive use of the straight drill revealed significant collateral damage forming a contrast to minor enlargement of the neoostium. The curved frontal sinus bur showed considerable technical insufficiencies.

CONCLUSIONS: Judicious use of the straight drill is recommended for those rare cases of therapy-resistant frontal sinusitis treated by an extended type of frontal sinusotomy. New technical refinements of the curved frontal sinus burs should be subjected to repeated evaluation.

OBJECTIVE: Analyze the variability of anatomic relations between the sigmoid sinus and other surgical landmarks within the mastoid cavity to establish a classification of sinus location to facilitate surgical planning.

STUDY DESIGN: A descriptive study of surgical landmarks using 96 temporal bones from the Temporal Bone Laboratory at the Department of Otorhinolaryngology, Valle University at Cali, Colombia.

METHODS: A dissection simulating a canal wall-up mastoidectomy extended to include exposure of the facial recess, epitympanum, and sigmoid sinus was performed on 96 adult disease-free temporal bones. Seven standard measurements were taken on each bone between the sigmoid sinus and other structures in the mastoid cavity. All data were analyzed using Epi-Info 2000.

RESULTS: This parametric study was consistent with three classes of anatomic variations in the location of the sigmoid sinus (type 1, type 2, and type 3) based on a Gaussian distribution of the seven variables.

CONCLUSIONS: Variability in the anatomic location of the sigmoid sinus in the mastoid cavity is common and has surgical relevance.

SIGNIFICANCE: This classification will help to rapidly identify the sigmoid sinus relationship within the mastoid cavity and to use the sigmoid sinus as a landmark during ear surgery in those cases in which traditional landmarks, such as the posterior auditory canal wall or the semicircular canals, are destroyed by a pathologic process.

OBJECTIVES: There is an increasing knowledge that the severity of perennial allergic rhinitis is associated with nasal carriage of Staphylococcus aureus (S. aureus). The aim of this study was to evaluate the rate of bacterial colonization with S. aureus in the nose of subjects with and without chronic rhinosinusitis (CRS) and to correlate these findings with the severity of symptoms and the extent of the disease.

STUDY DESIGN AND SETTING: Open, prospective controlled trial.

METHODS: 190 subjects with CRS and 42 subjects with septal deviation without sinusitis (control subjects) were included in this study. Swabs were taken endoscopically from the middle meatus and bacteria were cultured and identified. Airway symptoms were assessed by subjects in standardized questionnaires and frequencies of respiratory tract infections were noted. The rhinosinusitis extent was graded by CT scan assessment. Analysis of variance, chi-square test, and Pearson's correlation test were applied for statistical analyses.

RESULTS: The S. aureus carriage rate was 25.5% in CRS and 31.4% in control subjects. Further facultative pathogens were cultured in 20.6% of subjects with CRS and in 8.5% of controls. 73.8% of S. aureus were ampicillin-resistant, multiresistant strains were cultured in 5.8%. Most airway symptoms and the frequencies of respiratory tract infections were significantly higher in the CRS group compared with control subjects. In post hoc comparison between the subgroups with and without S. aureus colonization, no significant differences were found between the extent of rhinosinusitis and the severity of airway symptoms.

CONCLUSIONS: Facultative pathogens were detected in more than 40% of CRS patients without acute respiratory tract infections. In contrast to the findings in atopic dermatitis and perennial allergic rhinitis, the colonization rate with S. aureus is not increased and S. aureus carriage is not a risk factor for the severity or the extent of rhinosinusitis.

OBJECTIVE: To compare the clinical and bacteriologic efficacy and safety of short-duration treatment with telithromycin given for 5 days with moxifloxacin given for 10 days in adults with acute bacterial rhinosinusitis (ABRS).

STUDY DESIGN: In this prospective, double-blind, parallel-group, randomized, multicenter study, adult patients (N = 349) with ABRS were randomized to oral telithromycin (800 mg once daily for 5 days) or to oral moxifloxacin (400 mg once daily for 10 days) and followed for 31 to 36 days. Clinical outcome was determined by the investigator at the posttherapy/test of cure (TOC) visit. Bacteriologic outcome was determined by comparing cultures taken at the pretreatment visit with cultures obtained at the posttherapy/TOC visit. The primary objective was to demonstrate equivalence of clinical cure rates in the per-protocol population between treatment groups at the posttherapy/TOC visit.

RESULTS: Clinical success at TOC (primary endpoint) was achieved in 87.4% of patients in the telithromycin group compared with 86.9% for moxifloxacin (per-protocol patients; 0.5% difference between treatment groups; 95% confidence interval (CI), −8.1, 9.2; P = 0.8930). The bacteriologic success rates were 94.1% and 93.9%, respectively (0.2% difference between treatment groups; 95% CI, −14.2, 14.5; P = 0.9734). Overall treatment-emergent adverse events for both drugs (mostly gastrointestinal) were mild to moderate in intensity.

CONCLUSION AND SIGNIFICANCE: The clinical and bacteriologic efficacy of telithromycin 800 mg once daily for 5 days was equivalent to that of moxifloxacin 400 mg once daily for 10 days, establishing telithromycin as an important treatment option for ABRS.

OBJECTIVE: Examine the efficacy of epicutaneous and intradermal testing in predicting response to nasal provocation with timothy antigen.

STUDY DESIGN AND SETTING: Prospective study. Subjects were tested with Multi-Test II (MT). Subjects with negative wheals were tested with a 1:500 intradermal injection of timothy. They had baseline assessment of nasal cross-sectional area (CSA) using acoustic rhinometry and underwent nasal provocation with increasing timothy concentrations. CSA was assessed and nasal visual analog scale (VAS) completed with each concentration.

RESULTS: Sensitivity and specificity of MT in predicting nasal response to provocation were 87% and 86%. Intradermal testing increased sensitivity to 93%. Hierarchical linear modeling (HLM) demonstrated that subjects positive to skin testing had significant reductions in CSA and worsening VAS scores with increasing concentrations of nasally delivered antigen.

CONCLUSION AND SIGNIFICANCE: Epicutaneous testing with the Multi-Test II offers 87% sensitivity and 86% specificity in assessing timothy grass reactivity.

OBJECTIVE: Evaluate the multiple end-organ targets affected by intradermal testing (IDT)-based immunotherapy.

STUDY DESIGN AND SETTING: We conducted a retrospective medical record review of 139 patients, as well as a follow-up questionnaire in a university setting.

RESULTS: Statistically significant differences (t-tests, P < 0.05) were observed in the prevalence of symptoms after IDT-based immunotherapy for each category (ear, eye, nasal, and throat). When divided into treatment time groups, the reduction was less in the first group (0–6 months therapy), than the subsequent groups (6–24 months and >24 months). The reduction leveled off after 6 months of therapy, with no difference seen between the 6- to 24-month and >24-month groups.

CONCLUSIONS: IDT-based immunotherapy has a broad response on otolaryngic allergy symptoms that appears to be consistent over time.

SIGNIFICANCE: IDT-based immunotherapy is an effective form of treatment for allergy-induced diseases of the head and neck.

OBJECTIVE: To compare product attributes, preferences, and expected compliance associated with triamcinolone acetonide aqueous (TAA-AQ), fluticasone propionate (FP), and mometasone furoate (MF) nasal sprays in patients with allergic rhinitis.

STUDY DESIGN AND SETTING: Data from 2 randomized, double-blind crossover studies with identical design were pooled (N = 215). Patients completed a 14-item sensory attributes questionnaire immediately after each product, and stated their preference and expected compliance with a prescription after receiving all products.

RESULTS: Compared with FP and MF, TAA-AQ was associated with significantly less odor and greater liking of odor (P < 0.001); and less taste, less dryness of nose/throat, less aftertaste, and greater overall liking (P < 0.05). Significantly more patients preferred most a prescription of TAA-AQ (50.0%) versus FP (25.0%; P < 0.001) and MF (25.0%; P < 0.001), and would “definitely comply” with TAA-AQ (62.5%) versus FP (49.0%; P < 0.01) and MF (51.0%; P < 0.01).

CONCLUSION: TAA-AQ was associated with significantly more positive sensory attributes, higher preference, and better expected compliance than FP and MF.

SIGNIFICANCE: Patients' preferences for the sensory attributes of an intranasal corticosteroid may affect adherence to treatment.

OBJECTIVE: Short, self-report symptom questionnaires are useful in routine clinical situations for assessing the progress of disorders and the influence of interventions. The Voice Handicap Index-10 (VHI-10) and Vocal Performance Questionnaire (VPQ) are brief self-reported assessments of voice pathology, apparently useful in the general voice clinic population. Little is known of the structure or internal consistency of either tool, nor whether they correlate. This study carried out a substantial, systematic evaluation of their performance in the Laryngology office setting.

STUDY DESIGN AND SETTING: 330 adult (222 women, 108 men) voice clinic attenders completed the VHI and the VPQ. RESULTS: The VHI-10 and VPQ each had a large, single principal component, high internal consistency, and were highly correlated (dis-attenuated r=0.91).

CONCLUSION: The VHI-10 and the VPQ are similar, short, convenient, internally-consistent, unidimensional tools.

SIGNIFICANCE: The total VHI-10 or VPQ score is a good overall indicator of the severity of voice disorders.

OBJECTIVE: To evaluate the indications, results, and safety of revision Gore-Tex medialization laryngoplasty (GML).

METHODS: A retrospective chart review of 156 patients that underwent GML procedures between the years 1998–2002. Study population consisted of those patients who required revision surgery for any reason.

RESULTS: Sixteen patients required 22 revision procedures. Indications for revision were divided into 2 groups, complications and glottal closure problems. Complications included extruded or displaced implants (n = 4). The most common glottal closure problem was undercorrection (n = 9). Others included anterior overcorrection (n = 1) and persistent posterior glottal gap (n = 2). Revision procedures included GML (n = 9), injection augmentation (n = 9), endoscopic implant removal (n = 2), and arytenoid adduction (n = 2). In patients with glottal closure problems, the GCI improved in all 10 and the voice rating scale improved in 9.

CONCLUSION: Reasons for revision of GML are variable, the most common being undercorrection. A variety of safe, effective revision techniques are available with a high success rate.

OBJECTIVES: Because of the side effects of Teflon, the risk of infection from the use of collagen, autologous fat resorption, and the lack of alternative substances, injection laryngoplasty tends to be replaced by laryngeal framework surgery as the method of choice for the treatment of unilateral vocal cord recurrent paralysis (LP). The aim of this study was to evaluate the results, for morbidity and voice quality, of treating this paralysis by injection of a silicone suspension elastomer implant (SSEI).

STUDY DESIGN: The study was retrospective, and 19 patients were included. Average follow-up was 25 months (range: 8.3-43).

METHODS: Each patient underwent clinical and videostroboscopic assessment, and had an electroglottographic recording. Subjective assessment was obtained by self-evaluation. Results were classified as good, fair, or poor, and were based on 2 objective and 3 subjective criteria. A search was made for biologic signs of autoimmune disorders.

RESULTS: Good, fair, and poor results were respectively 79%, 16%, and 5%. Each set of subjective data showed voice improvement (P < 0.05). The fundamental frequency range, percentage of irregularity, and aspiration decreased significantly (P < 0.05). There was only one case of postoperative dyspnea, which resolved after steroid injection. No biologic signs of autoimmune disorders were found.

CONCLUSIONS: The use of SSEI is safe. Injection laryngoplasty is easy to perform and avoids cervical scarring. Its results are comparable to those obtained with other techniques, including laryngeal framework surgery, even if there is no standard criterion for the evaluation of voice quality. SSEI injection can reasonably be proposed as a surgical treatment for permanent unilateral vocal cord LP.

OBJECTIVE: To determine if Pseudomonas aeruginosa (PA) otitis media (OM) increases the risk of sensorineural hearing loss (SNHL) with semicircular canal transection in the guinea pig model.

METHODS: PA was injected transtympanically into both middle ears of pigmented guinea pigs. Saline-injected animals served as controls. Two to 4 days after injection, one horizontal semicircular canal was transected and sealed. Hearing was tested using electrocochleography before and after transection.

RESULTS: PA-OM was induced in all PA-injected ears. Five days after semicircular canal transection, click-evoked thresholds were significantly elevated in ears with PA-OM (P = 0.00009) but not in saline-injected ears (P = 0.398).

CONCLUSION: Violation of the inner ear in the presence of PA-OM is associated with increased risk of SNHL in the guinea pig.

SIGNIFICANCE: Factors unique to PA infection may be responsible for SNHL with labyrinthine injury in humans with chronic otitis media.

OBJECTIVES: A pseudomeningocele results from the escape of cerebrospinal fluid through a dural defect with trapping of subarachnold fluid in surrounding soft tissue. The present study evaluates the incidence of pseudomeningocele following neurotologic procedures and delineates an algorithm for management.

METHODS: A retrospective review of 375 consecutive patients undergoing neurotologic procedures at a single institution identified 17 patients with the postoperative complication of pseudomeningocele.

RESULTS: The incidence of pseudomeningocele formation was 4.5% in the present study. Fourteen pseudomeningoceles resolved with nonoperative management including pressure dressing, bed rest, and lumbar spinal drainage. Three patients failed nonoperative management and required surgical procedures for resolution. All patients ultimately had resolution of their pseudomeningocele.

CONCLUSION: Skull-base pseudomeningoceles occur as a complication following neurotologic procedures and can cause complications as they enlarge. The majority of these cases can be dealt with in a nonsurgical manner, but those failing to respond to conservative management should be considered for surgical intervention.

OBJECTIVES: To compare modifications in the surgical technique of congenital aural atresia (use of argon laser, thinner split-thickness skin graft, Silastic sheets in the external auditory canal, and Merocel wicks) by examining hearing results and complications before and after initiation of these changes.

STUDY DESIGN AND SETTING: Retrospective chart review of patients who underwent congenital aural atresiaplasty between 1985 and 2002 in a tertiary referral neurotologic private practice. Complication rates and hearing results were compared before (n = 36) and after (n = 80) modifications in the surgical technique.

RESULTS: Closure of the air-bone gap to 30 dB or less at short-term follow-up occurred in 63.1% of surgeries performed after modifications in the surgical technique and 44.5% of surgeries performed before these changes. The long-term postoperative air-bone gap was 30 dB or less in 50.0% of the surgeries performed after and 47.1% of the cases performed before the changes in surgical technique. Soft tissue stenosis and bony growth of the external auditory canal were seen in 3.8% of surgeries performed after and 13.9% of surgeries performed before the surgical technique changes. Ossicular chain refixation occurred in 3.8% of surgeries performed after and 25.0% of surgeries performed before such changes. There were no dead ears and no facial palsies.

CONCLUSION: The use of argon laser, thinner split-thickness skin graft, Silastic sheets in the external auditory canal, and Merocel wicks, as a group, has helped to improve hearing results and decrease the incidence of complications in congenital aural atresia surgery.

SIGNIFICANCE: Refinements in surgical techniques can lead to measurable improvements in outcome in atresiaplasty.

BACKGROUND: Amikacin is a semisynthetic aminoglycoside. It acts against most of the microbial species. Amikacin limitation of the therapeutic application is the ototoxicity which promotes permanent lesions in the cochlear system. Aminoglycoside antibiotics have ototoxic potential. The target cells are preferentially the outer hair cells in the cochlear basal turns. Amynoglicoside antibiotics can quelate iron forming a complex with oxidate properties and promotes the formation of free radicals. Responsible for production of lesions in the hair cells.

OBJECTIVE: The objective of the present investigation was to determine whether the use of the aminoglycoside amikacin at small doses may lead to the occurrence of some types of resistance to or protection against ototoxicity of the drug by analyzing lesions to the organ of Corti by scanning electron microscopy.

METHODS: The study was conducted on 31 guinea pigs that were divided into 4 groups, amikacin was administered intramuscularly. The groups consisted of: group A = control group: 5 animals (10 cochleae); group B = 5 animals (10 cochleae), amikacin 20 mg/kg/day for 30 days; group c = 7 animals (13 cochleae), amikacin 400 mg/kg/day for 12 days; group d = 14 animals (26 cochleae) amikacin 20 mg/kg/day for 30 days, followed by 400 mg/kg/day for 12 days. Histological studies were performed by scanning electron microscopy. Three cochleae were excluded.

RESULTS: In groups A and B, the cells were normal in all cochleae, in group C there were extensive lesions of the 2 more basal turns, and in group D there was a significant reduction of lesions in the 2 more basal turns compared with group C, which had received the ototoxic dose of amikacin alone.

CONCLUSION: We conclude that the non-ototoxic dose of amikacin administered before the ototoxic dose of the same antibiotic had a statistically significant protective effect on the 2 more basal turns of the guinea pig cochlea.

OBJECTIVES: Placebo response is defined as a change in health status resulting from the symbolic significance attributed by the patient or proxy to the physician encounter. Our goals were to validate the PR12 survey as a measure of placebo response and to analyze the placebo response as a discrete and measurable component of everyday office encounters with the otolaryngologist.

STUDY DESIGN: This was a prospective, before-and-after clinical outcomes study of 95 children aged 6 months to 12 years conducted in an academic metropolitan pediatric otolaryngology practice. Caregivers completed the PR-12 survey at entry and at least 4 weeks later. The survey included 3 domains (4 questions each) reflecting the main components of the placebo response: meaningful explanation, care and concern, and mastery and control. PR-12 was correlated with longitudinal change in health status at least 1 to 2 months after the baseline visit. Outcome measures included direct and indirect measures of change in disease-specific quality of life and satisfaction with change.

RESULTS: Test-retest reliability was fair for most PR-12 survey items (R = 0.41 to 0.76) but was higher for domains (0.60 to 0.66) and the overall survey score (0.66). PR-12 had excellent internal consistency (Cronbach's alpha 0.91) and appropriate construct validity. Caregiver satisfaction change at follow-up correlated with the PR-12 (r = -.25, P = 0.036). Conversely, no correlation was seen between the PR-12 and direct and indirect measures of change in disease specific quality of life.

CONCLUSION: Placebo response is an important and potentially measurable aspect of clinical encounters. PR-12 is a promising first step at creating a brief, reliable, and valid instrument to assess the placebo response.

SIGNIFICANCE: Reemphasizing the therapeutic potential of the doctor-patient relationship may improve quality of care and disease outcomes.

OBJECTIVE: Multiple biochemical and genetic strategies were used to downregulate early response gene NF-κB, whose activation controls squamous cell cancer-associated pathways.

STUDY DESIGN: NA cells, an oral cavity squamous cell cancer with high NF-κB activity, were cultured with biochemical NF-κB inhibitors TPCK and Calpain I inhibitor, as well as specific NF-κB antisense oligonucleotides. Cell proliferation was measured, as was NF-κB downregulation using functional luciferase reporter genes and electromobility shift assays.

RESULTS: Significant downregulation of cell proliferation and NF-κB functional activity were demonstrated with either biochemical inhibitor, as well as the antisense oligonucleotides; however, additional nonspecific toxicities were observed with control antisense oligonucleotides.

CONCLUSION AND SIGNIFICANCE: NF-κB is a potential target for squamous cancer treatment, as it is constitutively upregulated in vitro. Biochemical inhibition of NF-κB may be a viable treatment strategy for head and neck squamous cancers.

OBJECTIVE: Tissue ultrafiltration (TUF) is a method of reducing tissue edema by removal of interstitial fluid. Considering the deleterious effects of edema on microcirculation and tissue viability, the effect of TUF on skin flap survival was tested.

STUDY DESIGN AND SETTING: Survival of modified McFarlane skin flaps was determined in 40 Sprague-Dawley rats. In 20 treated animals, four 5-cm ultrafiltration catheters were placed in the subdermal plane of the distal flap 24 hours after flap elevation and connected to a down-regulated vacuum manifold for 8 hours. No catheters were placed in the control group.

RESULTS: Skin flap survival was improved in the experimental group (87.2 ± 1.6) over the control group (76.7 ± 2.2).

DISCUSSION: TUF effectively improved skin flap survival. These results provide evidence of the causal effect of edema on tissue viability. The relative ease of use of TUF would allow cost-effective clinical application of this technique.

OBJECTIVE: Our study was designed to find out the rate and the characteristics of micrometastasis in cervical lymph nodes using immunohistochemical staining.

STUDY DESIGN AND SETTING: From 69 patients, 1710 lymph nodes negative for metastasis on hematoxylin-eosin stain, were examined. Immunohisto-chemical stain was performed using pan-cytokeratin AE1/AE3 antibody.

RESULTS: In 13 cases, occult lymph node metastasis was detected by immunohistochemical method. On retrospective review of the hematoxylin-eosin stain by the pathologist, lymph node metastasis was detected in 4 of 13 patients.

CONCLUSIONS: Because the immunohistochemical method enhanced the detection rate of occult micrometastasis in cervical lymph nodes of head and neck squamous cell carcinoma patients, it may be recommended for routine diagnostic use in patient with negative for a lymph node metastasis on routine hematoxylin-eosin stain.

OBJECTIVES: This study retrospectively reviews the results of sclerotherapy using several sclerosants for congenital lesions of the head and neck.

METHODS AND PATIENTS: Between May 1990 and May 2002, patients with lymphatic malformations were treated by sclerotherapy; 10 with bleomycin, and 25 with OK-432. OK-432 sclerotherapy was also applied in 9 patients with plunging ranula and in 1 patient with branchial anomaly. Percutaneous sclerotherapy with ethanolamine oleate was used in 29 patients with venous malformations, and 28 patients with pyriform sinus fistula were treated by trichloroacetic acid chemocauterization.

RESULTS: Overall, two thirds of patients with these lesions showed marked to complete response. One case of mortality occurred in the bleomycin sclerotherapy group. However, no major complications by other sclerosants were found. In lymphatic malformations, history of excision before sclerotherapy was a poor prognostic factor.

CONCLUSION: Sclerotherapy using these sclerosants is a safe and effective primary treatment for congenital lesions in the head and neck.