Head and Neck Medicine by Alexandros G.Sfakianakis: 11/24/17

Παρασκευή 24 Νοεμβρίου 2017

The effectiveness of topical colloidal silver in recalcitrant chronic rhinosinusitis: a randomized crossover control trial

Abstract

Background

Recalcitrant chronic rhinosinusitis without polyposis (CRSsP) is a challenging condition to manage as traditional medical therapies and surgery fail to provide satisfactory clinical improvements. Colloidal silver (CS), a widely used naturopathic agent, has recently shown anti-biofilm properties both in vitro and within a rhinosinusitis animal model. To date, no trials involving humans have been published in world literature. The purpose of this study was to assess the efficacy of CS as a topical nasal spray in patients with refractory CRSsP.

Methods

A prospective cohort study was conducted using a convenience sample of 20 randomized patients with crossover methodology, comparing nasal sprays with CS versus saline. Patients sprayed twice daily for six weeks with the first intervention and then switched to the second for the next six weeks, with measurements made at baseline and each time point. Primary outcomes were changes in SNOT-22 and Lund-Kennedy (LK) endoscopic scores. All analysis was non-parametric and was conducted using STATA 14.

Results

Twenty-two patients were enrolled in the study with 20 completing the entire protocol. Mean 6-week change in SNOT-22 scores were −2.8 and 1.0 for saline and CS, respectively (p = 0.373). Similarly, mean 6-week change in LK scores were −1.4 and −1.1 for saline and CS, respectively (p = 0.794). Significant period effects were observed with the SNOT-22 score between the randomized groups. No participants experienced negative health effects directly attributable to the administration of intranasal CS.

Conclusion

Commercially available CS nasal spray did not demonstrate any meaningful subjective or objective improvements in patients with recalcitrant CRSsP.

Trial registration

NCT02403479. Registered on March 1, 2015.

http://ift.tt/2A5w67p

Clinical and genetic characteristics of xeroderma pigmentosum in Nepal

Summary

Background

Little is known about xeroderma pigmentosum (XP) in Himalayan countries.

Objective

To describe clinical characteristics of XP in Nepal and investigate its genetic bases.

Methods

This study was carried out on all consecutive patients referred for XP to a Nepalese tertiary referral centre in 2014-2015. Clinical data were collected using a standardized questionnaire. DNA was extracted from salivary samples and next generation sequencing (NGS) was conducted using a panel covering all 8 known XP genes (classical XP (XPA to XPG) and XP variant) and a skin cancer modifier gene, the melanocortin 1 receptor gene (MC1R).

Results

Seventeen patients (median age: 15 years; range: 1-32) were included. Twelve had skin cancers (including a total of 8 squamous cell carcinomas, 60 basal cell carcinomas, ocular carcinomas requiring an orbital exenteration in 3 patients, but no melanoma). Fifteen patients carried the same homozygous nonsense XPC mutation c.1243C>T, p.R415X. A homozygous nonsense XPA mutation (p.W235X) was found in the only patient with a history of early severe sunburn reaction and associated neurologic symptoms. Associated genetic alterations included heterozygous missense variants in XPD/ERCC2 gene and the presence of MC1R variant R163Q in 5 and 9 patients, respectively.

Conclusion

Although not previously reported, XP seems frequent in Nepal. Patients often presented with a very severe phenotype after a long history of excessive sun exposure without knowledge of the disease. 15/17 had the same p.R415X XPC mutation, which seems very specific of XP in Nepal, suggesting a founder effect. NGS analyses frequently revealed associated genetic alterations which could play a modifier role in the clinical expression of the disease.

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Non-melanoma Hutchinson's sign: A reappraisal of this important, remarkable melanoma simulant

Abstract

Background

More than 20 years ago our reappraisal of the Hutchinson Sign (HS) gave birth to the concept of the Pseudo-Hutchinson sign.

Objectives

We have found it interesting to emphasize some important histologic points and to expand the list of the numerous HS simulants.

Methods

We have examined the cutaneous samples taken from the pigmented skin of patients in association with nail matrix biopsy. We have also extended the long list of non-melanoma HS.

Results

Histologically HS may present only as an epidermal pigmentation, depending on the area sampled. Occasionally, there may be a sparse junctional melanocytic proliferation which does not demonstrate cytologic atypia due to an underlying melanocytic nevus of the nail matrix. However, early HS can show a melanoma in situ, with a HS at the proximal nail fold (PNF) and confluent atypical melanocytes in the nail matrix. Finally, involvement of the proximal nail fold, nail matrix and nail bed containing atypical melanocytes in irregular array may be seen.

Conclusion

The mere presence of periungual pigmentation is neither clinically nor histologically pathognomonic of subungual melanoma and justifies the usefulness of this work stressing the non-melanoma HS.

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In vivo Confocal Laser Microscopy for monitoring of actinic keratosis treatment: a comparison with histopathologic assessment after treatment with topical 5% 5-fluorouracil

Abstract

Background

Histological examination is the gold standard for actinic keratosis diagnosis; however, it is not always a feasible approach. Reflectance confocal microscopy (RCM) is a non-invasive technique that may be an alternative for monitoring actinic keratoses treatment response. Topical 5-fluorouracil is indicated for actinic keratosis multiple lesions and for field cancerization treatment.

Objectives

To assess the RCM accuracy, sensibility and specificity for actinic keratosis, considering as a gold-standard the histopathological examination; as well as to evaluate the efficacy of 5% 5-fluorouracil treatment.

Methods

This is a prospective study in actinic keratosis patients between August, 2014 and November, 2015. RCM analyses were performed in one randomly selected actinic keratosis lesion of the upper limbs by two independent observers before and after 5% 5-fluorouracil treatment. At the end of treatment and with clinical bleaching of treated lesions, histological examination was performed by two pathologists.

Results

A total of 50 lesions were enrolled, and 40 lesions presented complete clinical bleaching after treatment and were included in the final analysis. Accuracy, sensibility and specificity means among observers were 83.8%, 84.6% and 83.3%, respectively. After 5-fluorouracil treatment, actinic keratosis was diagnosed in 45.0% (observer 1) and 32.5% (observer 2) of subjects according to RCM and in 32.5% of subjects according to histological examination. Considering RCM observers diagnosis, the concordance was substantial (k 0,637, p<0,001). 5-fluorouracil led to a reduction in 55.0%-67.5% of actinic keratoses according to RCM analysis.

Conclusion

This study allows to validate of RCM as a non-invasive method capable of monitoring actinic keratosis therapeutic response to 5-fluorouracil, presenting efficacy comparable to histological examination. Additionally, the results suggest that 5-fluorouracil may be a satisfactory option for therapeutic control of this condition.

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Novel device-based acne treatments: comparison of a 1,450-nm diode laser and micro-needling radiofrequency on mild to moderate acne vulgaris and seborrhea in Korean patients through a 20-week prospective, randomized, split-face study

Abstract

Background

While device-based acne treatments are widely applied for patients not tolerating conventional medications, related controlled studies have been still limited. Recently, non-ablative 1,450-nm diode laser (DL) and fractional micro-needling radiofrequency (FMR) have been effectively used for acne, in addition to well-recognized dermal remodeling effects.

Objective

To compare the clinical course for acne treatment between DL and FMR.

Methods

Twenty five Korean patients with mild to moderate facial acne completed treatments with DL and FMR through a 20-week, randomized split-face study. One randomly assigned half side of each patient's face received DL and the other side by FMR. Treatments were scheduled to receive three consecutive sessions at 4-week intervals. Objective assessments including revised Leeds grades, lesion counts, sebum output measurements, and patients' subjective satisfaction were investigated.

Results

Both DL and FMR demonstrated steady improvement of acne and seborrhea during treatment sessions. While results between two devices were similar during treatment sessions, FMR was superior to DL in the 12-week follow up. Patients' subjective assessments for seborrhea improvement were similar between two devices, while those for acne, skin texture, and acne scars were more satisfactory for FMR. For safety proflie, no significant difference was observed between two regimens, while mild post inflammatory hyperpigmentation was observed only in DL side.

Conclusion

Both DL and FMR demonstrated efficacies for acne and seborrhea, with reasonable safety proflie. FMR was more effective than DL for the long-term maintenance, and subjective assessments for texture and scar improvements. Therefore, a few sessions of these devices would be a viable option for acne treatments.

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Educational and Practice Gaps in the Management of Volar Melanocytic Lesions

Abstract

Background

The benign and malignant patterns of acral melanocytic nevi (AMN) and acral melanomas (AM) have been defined in a series of retrospective studies. A 3-step algorithm was developed to determine when to biopsy acral melanocytic lesions. This algorithm has only been applied to a Japanese population.

Objectives

Our study aimed to review the current management strategy of acral melanocytic lesions and to investigate the utility of the 3-step algorithm in a predominately Caucasian cohort.

Methods

A retrospective search of the pathology and image databases at Mayo Clinic was performed between the years 2006 – 2016. Only cases located on a volar surface with dermoscopic images were included. Two dermatologists reviewed all dermoscopic images and assigned a global dermoscopic pattern. Clinical and follow-up data was gathered by chart review. All lesions with known diameter and pathological diagnosis were used for the 3-step algorithm.

Results

Regular fibrillar and ridge patterns were more likely to be biopsied (p=0.01). The majority of AMN (58.1%) and AM (60%) biopsied were due to physician-deemed concerning dermoscopic patterns. 39.2% of these cases were parallel furrow, lattice-like, or regular fibrillar. When patients were asked to follow-up within a 3-6-month period, only 16.7% of the patients returned within that interval. The 3-step algorithm would have correctly identified 4/5 AM for biopsy, missing a 6mm, multi-component, invasive melanoma.

Conclusion

We found one major educational gap in the recognition of low risk lesions with high rates of biopsy of the fibrillary pattern. Recognizing low-risk dermoscopic patterns could reduce the rate of biopsy of AMN by 23.3%. We identified two major practice gaps, poor patient compliance with follow up and the potential insensitivity of the 3-step algorithm to small multi-component acral melanocytic lesions.

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Cutaneous granuloma caused by Rhizopus oryzae with a novel mutation in the CYBB gene in a monozygotic male twin

Abstract

A 2-year-old Chinese boy presented to our institution with a large lump in the sacrococcygeal region for two months, along with fever for five days. The initial lesion presented as a red papule accompanied by itching, and then progressed to 10 cm in diameter (Fig. 1a). Five days previously, the patient had developed a fever.

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Response to – Bullous pemphigoid inguinalis?

Abstract

We appreciate the constructive comments by author Abdelmaksoud in response to our report of bullous pemphigoid (BP) presenting in association with metastatic penile squamous cell carcinoma (SCC). Though our patient had few blisters on the back, upper limbs and oral cavity, the chief brunt of the disease was on the inguinal area. Cases of localized BP, arising after radiotherapy for breast carcinoma have been reported. Our patient developed BP before receiving radiotherapy.

http://ift.tt/2jmRxqy

Bullous Pemphigoid Inguinalis?

Abstract

I read with great interest a case report by Bishnoi et al. published recently in the journal of European Academy of Dermatology and Venereology. The authors presented a case of a 43-year old man who had history of penile SCC, presented with bullous pemphigoid (BP) lesions. Interestingly, the BP lesion was limited to the inguinal region, suprapubic area and inner aspect of the right thigh, that was predominantly on top of the bilateral metastatic inguinal lymphadenopathy(LN).

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Electrochemotherapy of unresectable cutaneous tumors with reduced dosages of intravenous bleomycin: analysis of 57 patients from the InspECT (International network for sharing practices of ElectroChemoTherapy) registry

Abstract

Background

Electrochemotherapy (ECT) is currently used to treat unresectable superficial tumors of different histotypes through the combination of cytotoxic chemotherapy and local application of electric pulses. In 2006, a collaborative project defined the ESOPE (European Standard Operating Procedures of Electrochemotherapy) guidelines to standardize the procedure. The International Network for Sharing Practices of Electrochemotherapy (InspECT) aims to to refine the ESOPE and improve clinical practice. Limiting patient exposure to systemic chemotherapy would be advisable in order to ameliorate ECT safety profile.

Objective

The aim of this study was to evaluate the efficacy and toxicity of ECT with reduced chemotherapy dosages.

Methods

In a retrospective analysis of a prospectively maintained database (InspECT registry), we evaluated the outcome of patients who received ECT with reduced dosages of bleomycin (7.500, 10.000, or 13.500 IU/m², instead of the standard dose of 15.000 IU/m²). Tumor response in melanoma patients was compared with melanoma patients of the InspECT registry who received the standard dose of bleomycin.

Results

We identified 57 patients with 147 tumors (melanoma, 38.6%; squamous cell carcinoma, 22.8%; basal cell carcinoma, 17.5%; breast cancer 7%, Kaposi sarcoma 7%, other histotypes, 7.1%. Per-tumor complete response (CR) rate at 60 days was 70.1% (partial, 16.3%); per-patient CR was 57.9% (partial, 21.1%). Local pain was the most frequently reported side effect (n=22 patients [39%], mostly mild; 2 patients experienced flu-like symptoms, 1 patient nausea. We observed the same CR rate (55%) in melanoma patients treated by reduced or conventional bleomycin dosages (p=1.00).

Conclusions

ECT performed with reduced bleomycin dosages could be as effective as with currently recommended dose. Patients with impaired renal function or candidate to multiple ECT cycles could benefit from a reduced dose protocol. Our findings need prospective confirmation before being adopted in clinical practice.

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Does obesity cause a distinct phenotype of hidradenitis suppurativa?

Abstract

I have read the article by Theut Riis et al proposing BMI based clinical subtypes of hidradenitis suppurativa (HS) patients with interest. In addition to giving valuable clinical information, the article is important in the discussion of the pathophysiology of such HS subgroups, with focus on the obese subtype. The papers main difference from earlier clinical proposals of subtyping is the focus on the body mass index (BMI) as a functional factor in the disease evolution.

http://ift.tt/2A8kfmL

Dimensions of hard and soft tissue around adjacent, compared with single-tooth, zirconia implants

Preservation or regeneration of the papilla has always been a challenge around consecutive implants or with implants next to teeth, and many studies have evaluated the papilla's behaviour and patterns based on surgical technique and prosthetic design, though evidence about its behaviour around zirconia implants is scarce. The aim of this study was to evaluate papilla behaviour between implants and teeth (tooth-implant group) and between consecutive implants (implant–implant group). Ninety patients with 122 zirconia implants (Straumann® PURE Ceramic Implant) were examined at the one-year follow up.

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Recurrence of oral mucocoeles in adolescents after excision

Although mucocoeles can occur at any age, children and adolescents are most commonly affected, and excision is the most common treatment.1

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Upregulation of angiogenesis in oral lichen planus

Abstract

Objectives

Since angiogenesis is fundamental to the pathogenesis of many chronic inflammatory disorders this study investigated the expression of various vascular markers in oral lichen planus and non-specific oral mucosal inflammatory tissues.

Methods

Archival specimens of oral lichen planus (n=15) and inflamed tissues (n=13) were stained using immunohistochemistry with antibodies to CD34, vascular endothelial growth factor, vascular endothelial growth factor receptor and vasohibin. Nine representative sites at the epithelial-connective tissue junction and through the fibrous connective tissue were selected and automated analysis techniques were used to determine the extent of positivity expressed as the percentage of positive cells. Significance was denoted when p<0.05.

Results

The expression of pro-angiogenic factors was higher in lichen planus samples compared with inflamed controls. A higher level of CD34 was observed in the deeper parts of the connective tissue of OLP (p=0.04), whereas VEGF and VEGFR2 expression was higher all through the tissues (respectively p<0.02 and p<0.01). The expression of the anti-angiogenic VASH1 was higher in inflamed tissue compared with lichen planus in all sites evaluated (p<0.01).

Conclusions

The findings indicate that angiogenic factors are differentially expressed in oral lichen planus compared with inflamed controls, with increased expression of pro-angiogenic factors and decreased anti-angiogenic expression.

http://ift.tt/2B9jtoT

Clinical effects of submucosal middle turbinectomy for eosinophilic chronic rhinosinusitis

The preservation or resection of the middle turbinate (MT) during endoscopic sinus surgery (ESS) currently remains a matter of debate. The present study aimed to investigate the effects of submucosal middle turbinectomy (SMT) in ESS for eosinophilic chronic rhinosinusitis (ECRS).

http://ift.tt/2hRZgfM

The association between atopic dermatitis and hand eczema: a systematic review and meta-analysis

Abstract

Atopic dermatitis (AD) and hand eczema (HE) are common chronic and relapsing inflammatory skin conditions that often co-occur. While several studies have addressed their relationship, the exact association estimate is unknown. We systematically reviewed published literature on the association between AD and HE in PubMed, Embase, and Web of Science using the following search terms; (atopic dermatitis OR atopic eczema) AND (hand dermatitis OR hand eczema). Meta-analyses were then performed to examine the association between AD and the point-, one-year- and lifetime prevalence of HE, respectively. We identified 35 relevant studies, of which 26 were included in the meta-analyses. AD was associated with an increased prevalence of HE with regards to point- (odds ratio (OR) 2.35; 95% CI: 1.47-3.76), one-year- (OR 4.29; 95% CI: 3.13-5.88), and lifetime prevalence (OR 4.06; 95% CI: 2.72-6.06). Furthermore, positive associations between AD and occupational HE were identified when assessing the one-year- 4.31 (95% CI: 2.08-8.91) and lifetime prevalence (OR 2.81; 95% CI: 2.08-3.79). Similar positive associations were found in the general population studies, i.e. OR 4.19 (95% CI: 3.46-5.08) and OR 5.69 (95% CI: 4.41-7.36). Important study limitations include the wide use of questionnaire studies, and lack of prospective studies as well as poor clinical phenotype descriptions. In conclusion, our systematic review and meta-analysis showed that patients with AD had a strongly increased prevalence of HE. Clinicians should continue to guide patients with AD away from occupations with high risk of HE.

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Validation study of the Vitiligo Extent Score-plus (VESplus)

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Estimating the cost of skin cancer detection by dermatology providers in a large healthcare system

Data on the cost and efficiency of skin cancer detection through total body skin examination (TBSE) are scarce.

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Future Considerations for Clinical Dermatology in the Setting of 21st Century American Policy Reform: The Relative Value Scale Update Committee

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Lack of correlation of the patient derived vitiligo disease activity index (VIDA) with the clinician derived vitiligo activity severity index (VASI)

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Drug survival of secukinumab in real-world plaque psoriasis patients: a 52-week, multicenter, retrospective study

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Differentiating Merkel cell carcinoma of lymph nodes without a detectable primary skin tumor from other metastatic neuroendocrine carcinomas: the ELECTHIP criteria

-Merkel cell carcinoma may initially present in lymph nodes without an evident primary skin tumor.-When this occurs the tumor may be misdiagnosed as lymph node metastasis from other neuroendocrine carcinomas. -The ELECTHIP criteria assists in differentiating between these diagnoses and may help classify patients with neuroendocrine lymph node metastasis.

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Characterization of epitope specificities of reference antibodies used for the quantification of the birch pollen allergen Bet v 1

Abstract

Background

Accurate allergen quantification is needed to document the consistency of allergen extracts used for immunotherapy. Herein, we characterize the epitope specificities of two monoclonal antibodies used in an ELISA for the quantification of the major birch pollen allergen Bet v 1, established as a reference by the BSP090 European project.

Methods

The ability of mAbs 5B4 and 6H4 to recognize Bet v 1 isoforms was addressed by immunochromatography. The capacity of each mAb to compete with patients' IgE for binding to Bet v 1 was measured by ELISA inhibition. Epitope mapping was performed by pepscan analysis, site-directed mutagenesis and hydrogen/deuterium exchange-mass spectrometry.

Results

The 5B4 epitope corresponds to a peptide sequence (I56-K68) overlapping with the binding sites of patients' serum IgEs. Mutation of residues P59, E60 and K65 abolishes 5B4 binding to Bet v 1 and reduces the level of IgE recognition. In contrast, 6H4 recognizes a conformational epitope lying opposite to the 5B4 binding site, involving residues located in segments I44-K55 and R70-F79. Substitution of E45 reduces the binding capacity of 6H4, confirming that it is critical for the interaction. Both mAbs interact with >90% of Bet v 1 content present in the birch pollen extract, while displaying a weak cross-reactivity with other allergens of the PR-10 family.

Conclusions

MAbs 5B4 and 6H4 recognize structurally distinct epitopes present in the vast majority of Bet v 1 isoforms. These results support the relevance as a reference method of the Bet v 1-specific quantitative ELISA adopted by the European Pharmacopoeia.

http://ift.tt/2zAEz34

Dermoscopy of different stages of lymphomatoid papulosis

Abstract

A 47-year-old man presented with a 3-year history of asymptomatic, erythematous papules and nodules located on his trunk, buttocks and limbs (Fig.1). Lesions were at different stages of clinical development: some were crusted or ulcerated, other necrotic or cicatricial. The patient's medical history was not relevant.

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All you should know about sunken eyes

A look at the condition of sunken eyes, where the eyes seem deep set and darkened. Included is detail on home remedies and when to see a doctor.

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Matching-Adjusted Indirect Comparison of Efficacy in Patients with Moderate-to-Severe Plaque Psoriasis Treated with Ixekizumab Versus Secukinumab

Abstract

Background

Head-to-head randomised studies comparing ixekizumab and secukinumab in the treatment of psoriasis are not available.

Objective

Assess efficacy and quality of life with ixekizumab vs. secukinumab treatment using matching-adjusted indirect comparisons.

Methods

Psoriasis Area and Severity Index (PASI) improvement of at least 75%, 90% and 100% and Dermatology Life Quality Index (DLQI) 0/1 response rates for approved doses of ixekizumab (160 mg at Week 0, then 80 mg every two weeks for the first 12 weeks) and secukinumab (300 mg at Weeks 0, 1, 2, 3 and 4, then 300 mg every 4 weeks) treatment were compared using data from active (etanercept and ustekinumab) and placebo-controlled studies. Comparisons were made using the Bucher (BU) and two modified versions of the Signorovitch method (SG total and SG separate). Subsequently, results based on active treatment common comparators were combined using generic inverse-variance meta-analysis.

Results

In meta-analysis of studies with active comparators, PASI 90 response rates were 12.7% (95% CI: 5.5%-19.8%; p=0.0005), 10.0% (2.1%-18.0%; p=0.01) and 11.2% (3.2%-19.1%; p=0.006) higher and PASI 100 response rates 11.7% (5.9%-17.5%; p<0.001), 12.7% (6.0%-19.4%; p<0.001) and 13.1% (6.3%-19.9%; p<0.001) higher for ixekizumab compared to secukinumab using BU, SG total and SG separate methods. PASI 75 results were comparable when SG methods were used and in favor of ixekizumab using BU method. Week 12 DLQI 0/1 response rates did not differ significantly.

Conclusion

Ixekizumab had higher PASI 90 and PASI 100 responses at Week 12 compared to secukinumab using adjusted indirect comparisons.

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Concomitant sensitization to legumin, Fag e 2 and Fag e 5 predicts buckwheat allergy

Abstract

Background

Buckwheat (Fagopyrum esculentum) has become increasingly popular as a healthy food in Europe. However, for sensitized individuals, consumption can cause anaphylactic reactions. The aim of this study was to identify individual well-characterized buckwheat allergens for component resolved diagnosis.

Methods

Patients were selected by positive skin prick test to buckwheat and divided into two groups: (1) sensitized to buckwheat without clinical symptoms and (2) buckwheat allergy. Buckwheat proteins were extracted from raw buckwheat seeds, purified applying a combination of protein precipitation and chromatographic methods and analyzed by IgE immunoblotting and ELISA.

Results

Buckwheat-allergic patients had a significantly larger median skin prick test wheal diameter for buckwheat than the sensitized group and the positive control. Also, IgE-immunoblotting clearly showed a distinct pattern in sera from allergic patients when compared to sensitized individuals. Several IgE-reactive proteins were purified from crude buckwheat extract, namely legumin (Fag e 1 plus its large subunit), Fag e 2 (2S albumin), and newly identified Fag e 5 (vicilin-like) as well as hevein-like antimicrobial peptides, designated Fag e 4. All four allergens showed superior diagnostic precision compared to extract-based ImmunoCAP with high sensitivity as well as high specificity.

Conclusions

Patients with clinical symptoms clearly show a distinct allergen recognition pattern. We characterized a buckwheat vicilin-like protein as a new relevant marker allergen, designated Fag e 5. Additionally, another new allergen, Fag e 4, potentially important for cross-reactivity to latex was added to the allergen panel of buckwheat. Further, our data show that the full-length legumin comprising both, large and small subunit should be applied for component resolved diagnosis. Our data indicate that concomitant sensitization to legumin, Fag e 2 and Fag e 5 predicts buckwheat allergy.

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AHNS Series: Do you know your guidelines? Principles of treatment for locally advanced or unresectable head and neck squamous cell carcinoma

Abstract

This article is a continuation of the "Do You Know Your Guidelines" series, initiated by the Education committee of the American Head and Neck Society. Treatment guidelines for advanced head and neck squamous cell carcinoma are reviewed here, including the critical roles of radiotherapy, chemotherapy, and the recent application of immunotherapy agents. We will be limiting this discussion to include cancers of the oral cavity, oropharynx, hypopharynx, and larynx. It should be noted that much of the article pertains to human papillomavirus (HPV)-negative oropharyngeal cancer where applicable, as HPV-positive oropharyngeal squamous cell carcinoma carries a different natural history, different prognosis, and now different staging criteria. Additionally, the article will not include information on nasopharyngeal or sinus cancers, as these latter topics are covered in separate "Do you know your guidelines?" installments and these diagnoses carry somewhat different approaches to diagnosis and management that diverge from the focus of this article.

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IMRT vs 2DRT for NPC Patients

Condition: NPC
Interventions: Radiation: IMRT; Radiation: 2DRT
Sponsor: Chinese University of Hong Kong
Not yet recruiting

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Efficacy Of Clinical Pilates Exercises İn Desk-Based Workers With Sagital Cervical Disorientation

Condition: Sagital Cervical Disorientation
Interventions: Other: clinical pilates exercises; Other: home exercises program
Sponsor: Eastern Mediterranean University
Recruiting

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Meta-analysis of induction chemotherapy as selection marker for chemoradiation in the head and neck

Objective

Many trials incorporate induction chemotherapy (IC) in selecting for organ preservation in head and neck squamous cell carcinomas (HNSCC). However, few studies examine IC response in predicting for chemoradiation therapy (CRT) response. This meta-analysis aims to determine the predictive accuracy of IC for subsequent response to CRT and overall survival (OS).

Data sources

Medline, EMBASE, Cochrane register.

Methods

A systematic search identified studies from database inception to October 2016 that used IC prior to CRT as definitive treatment for advanced HNSCC. The sensitivities and specificities of IC response predicting for complete CRT response were calculated, and the results were pooled in a summary receiver operating curve. One-, 2- and 5-year OS data were extracted.

Results

Seven studies (n = 423 patients) were analyzed for response and six (n = 439) for OS. Pooled median sensitivity and specificity of IC response predicting CRT response were 0.95 (95% confidence interval [CI]: 0.72–0.98) and 0.43 (95% CI: 0.00–0.61), respectively. Patients were more likely to respond to CRT given previous response to IC (positive likelihood ratio = 1.6; 95% CI: 1.21–2.11) and less likely to respond to CRT if they failed to respond to IC (negative likelihood ratio = 0.16; 95% CI: 0.07–0.38). At 2 years, good response to IC was a statistically significant prognostic marker with a risk ratio of 1.35 (95% CI: 1.12–1.64).

Conclusion

Our data suggests that patients with poor IC response will have poorer response to CRT and should be directed to other modalities. In contrast, good IC response does not guarantee a favorable outcome to CRT; however, because these patients are likely to have better prognoses, they should be offered salvage therapies of curative intent despite treatment failure.

Level of Evidence

NA. Laryngoscope, 2017

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Anaphylactic shock following castor bean contact: a case report

The castor bean plant, Ricinus communis, is known to have allergenic and toxic properties. Castor bean allergy has been described mainly as an occupational inhalation allergy in laboratory workers, in persons wor...

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Potential treatment for vocal fold scar with pirfenidone

Objectives/Hypothesis

Pirfenidone (PFD) is a strong antifibrotic agent that has been clinically approved in Japan for idiopathic pulmonary fibrosis. We examined the antifibrotic effects of PFD on fibroblasts isolated from scarred vocal folds (VFs) of ferrets in vitro.

Study Design

Prospective animal experiments with controls.

Methods

Scar fibroblasts (SFs) were isolated from scarred VFs that had been electrocauterized 2 weeks before harvesting (N = 4). Normal fibroblasts (NFs) were isolated from intact VFs (N = 4). SFs and NFs were incubated in the presence of 10 ng/mL transforming growth factor β1 (TGF-β1), with or without PFD. After the 48-hour incubation, mRNA expression levels of α smooth muscle actin (αSMA), TGF-β1, collagen type I, and hyaluronan synthase 2 (HAS2) were examined by real-time polymerase chain reaction. Immunohistochemistry with anti-αSMA anti-collagen type I and phosphorylated Smad (p-Smad)2/3 antibodies in SFs with or without PFD was performed. SFs and NFs were cultured in collagen gel with or without PFD for 48 hours, and the extent of gel contraction was examined quantitatively.

Results

PFD treatment significantly (P < .05) decreased mRNA expression of collagen type I, significantly increased mRNA expression of TGF-β1 and HAS2, and significantly suppressed collagen gel contraction. However, it did not have a significant effect on the expression of αSMA. The expression of p-Smad2/3 in the nucleus was faded with PFD, possibly demonstrating the suppression of translocation of p-Smad2/3 from cytoplasm to nucleus with PFD.

Conclusions

This is the first report to demonstrate the in vitro antifibrotic effects of PFD on fibroblasts isolated from scarred VFs of ferrets.

Level of evidence

NA Laryngoscope, 2017

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Teaching frontal sinus anatomy using the frontal sinus masterclass 3- D conceptualization model

Objective

Frontal sinus anatomy is complex and often is a difficult subject to both teach and learn. The traditional surgical dogma of "see one, do one, teach one" is impractical and dangerous in the frontal sinus. Based on the building block three-dimensional conceptualization module, the Frontal Sinus Masterclass (FSMC) was created to teach this anatomy.

Methods

Study was performed at two academic centers among second- to fifth-year otolaryngology residents. A pretest assessed knowledge prior to the course. Computed tomography scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy. Subsequently, the course instructor explained the anatomy using the building block method and showed a short video of the surgical dissection, pointing out relevant anatomy. Cases progressed in anatomical difficulty and inflammatory load. A posttest determined knowledge after the course.

Results

Thirty of 50 participating residents completed the pre- and posttests (14 junior, 16 senior residents). Correct identification of the frontal sinus drainage pathway increased from 42% to 63% correct (P = 0.054). Anatomical assessment increased from 61% to 68% correct (P = 0.047), and overall assessment increased from 52% to 66% correct (P = 0.016).

Conclusion

Objectively, participants of the FSMC expanded on their ability to recognize cells of the frontal recess on CT scans. Before the class, residents could answer less than half of the answers correctly, and by the end of the class they were answering over two-thirds of these complex questions correctly. Subjectively, participants reported benefit from the course and felt they would be better surgeons.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2A7PYo3

Does the diameter of the stapes prosthesis really matter? A prospective clinical study

Objectives/Hypothesis

To evaluate the influence of the diameter of stapes prosthesis on functional outcomes in stapes surgery.

Study Design

Prospective cohort study.

Methods

Fifty consecutive small fenestra stapedotomies performed using a 0.4-mm-diameter prosthesis were compared with 50 consecutive small fenestra stapedotomies carried out using a 0.6-mm-diameter piston. Audiological assessment following the recommendations of the Committee on Hearing and Equilibrium was performed 1 month after surgery. Postoperative complications between the two groups were noted.

Results

There were no statistically significant differences in demographic data between the two groups, and no differences in preoperative bone-conduction (BC) or air-conduction (AC) hearing thresholds for all frequencies (analysis of variance [ANOVA] and χ² tests). No differences were found in the mean preoperative BC and AC pure-tone average and air-bone gap (ABG). In the postoperative evaluation, a statistically significant difference was found for the mean AC gain (20 ± 8.7 vs. 24 ± 11.5, P = .042, ANOVA) as well as for the postoperative AC threshold at 0.125 and 0.25 kHz and the postoperative BC threshold at 0.25 kHz (P < .01, ANOVA). A postoperative ABG ≤10 dB was obtained in 90% and 94% of patients in the 0.4-mm- and 0.6-mm-diameter piston groups, respectively (difference not significant, χ² test). No postoperative dead ear and/or sensorineural hearing loss was noted in either group.

Conclusions

The 0.6-mm piston allowed a statistically significant higher AC gain compared with the 0.4-mm diameter piston. A larger diameter piston may be preferable if there are no anatomical or technical reasons that would favor a smaller prosthesis.

Level of Evidence

2b Laryngoscope, 2017

http://ift.tt/2jkP9R9

Long-term outcomes in unilateral vocal fold paralysis patients

Objectives/Hypothesis

At presentation, unilateral vocal fold paralysis (UVFP) patients have different treatment options, including conservative management (CM), injection laryngoplasty (IL) with a temporary agent, or permanent medialization (PM). This study evaluates long-term outcomes for UVFP patients relative to intervention.

Study Design

Retrospective chart review.

Methods

A retrospective chart review was performed of UVFP patients who presented to the University of California San Francisco Voice and Swallowing Center. Videolaryngostroboscopy examinations were reviewed. Maximum glottic closure was quantified with the normalized glottic gap area (NGGA). Perceptual voice analysis was performed using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) at corresponding time points.

Results

Fifty-three patients met inclusion criteria. Six underwent CM only, 20 went on to require PM, 19 underwent IL only, and eight underwent IL and subsequent PM. NGGA at presentation was similar among groups; however, the CM group was noted to have more favorable CAPE-V scores for Breathiness (P = .007) and Loudness (P = .018). All groups had similar NGGA and CAPE-V scores at last follow-up. When compared to pooled data for patients who underwent PM, the IL group was noted to have similar NGGA and CAPE-V scores at presentation. Although improvements in both groups were noted following intervention, both groups appeared similar at last follow-up with the exception of Roughness, for which the IL group retained a slightly improved outcome (13.3 vs. 18.3, P = .03).

Conclusions

At presentation, UVFP patients have similar NGGA. This finding suggests that treatment recommendations cannot be made on the size of the glottic gap alone. Furthermore, in many patients, IL results in long-term benefit with glottic closure and CAPE-V scores equivalent to that obtained with PM.

Level of Evidence

4 Laryngoscope, 2017

http://ift.tt/2A7G1Hs

Investigation of the presence of HPV on KTP laser fibers following KTP laser treatment of papilloma

Objectives

Recurrent respiratory papillomatosis is often treated with in-office laser procedures using a potassium titanyl phosphate (KTP) laser transmitted through a laser fiber. Although effective, this procedure has notable downsides, including the possibility of transmitting human papillomavirus (HPV) in the smoke plume and the high cost of these single-use fibers. The objective of this study is to determine if HPV can be detected on a laser fiber after use, with or without sterilization.

Methods

Twelve patients with laryngeal papillomas were treated with KTP laser energy transmitted via a KTP fiber. Ten fibers were sterilized in CIDEX (ASP, Irvine, California), a glutaraldehyde disinfectant, for 12 minutes, whereas two fibers were left unsterilized. Human papillomavirus DNA amplification was done on all 12 fiber samples with real-time polymerase chain reaction (PCR) using general primer mediated 5+ and 6+. Human papillomavirus genotyping detection was done using type specific probes and/or Sanger sequencing.

Results

Over 27 strains of HPV were not detected on KTP fibers after use, with or without sterilization.

Conclusion

Human papillomavirus was undetectable by PCR on KTP laser fibers that were sterilized or unsterilized after use. Further studies are needed utilizing a transmission model to determine if HPV can be incubated from this fiber after sterilization.

Level of Evidence

NA. Laryngoscope, 2017

http://ift.tt/2jjncJo

Relationship between degree of obstruction and airflow limitation in subglottic stenosis

Objectives

Subglottic stenosis (SGS) is one of the most common airway disorders in pediatric patients. Currently, treatment decisions rely primarily on the Cotton-Myer scale, which classifies SGS severity based on percentage reduction in airspace cross-sectional area (CSA). However, the precise relationship between upper airway resistance and subglottic CSA is unknown. We hypothesize that airway resistance can be described by the Bernoulli Obstruction Theory, which predicts that airway resistance is inversely proportional to airspace CSA ( inline image ) in cases of severe constriction.

Methods

Computed tomography (CT) scans of six healthy subjects and five SGS patients were used to create three-dimensional models of the respiratory tract from nostrils to carina. Cylindrical segments of varying lengths and varying diameters were digitally inserted in the subglottis of the healthy subjects to create simulated SGS models. Computational fluid dynamics simulations were run, and airway resistance was computed in the simulated SGS models and actual SGS models.

Results

Constriction diameter had a greater impact in airway resistance than constriction length. In agreement with the Bernoulli Obstruction Theory, airway resistance in the simulated SGS models was well represented by the power law inline image , where is a constant and the exponent b ranged from −0.85 to −1.07. The percentage reduction in airflow at a constant pressure drop was found to be directly proportional to the percentage reduction in CSA in the limit of severe constrictions, namely , where . Airway resistances in the simulated SGS models were similar to resistances in models based on CT scans of actual SGS patients, suggesting that our simulated SGS models were representative of airway resistance in actual SGS patients.

Conclusion

Our computer simulations suggest that the degree of airflow limitation in SGS patients may be estimated based on anatomic measurements alone. Future studies are recommended to test these predictions in larger cohorts.

Level of Evidence

4. Laryngoscope, 2017

http://ift.tt/2A6HUE7

Oral sampling methods are associated with differences in immune marker concentrations

Objective

To determine whether the concentration and distribution of immune markers in paired oral samples were similar.

Study Type

Clinical research.

Study Design

Cross-sectional study.

Methods

Paired saliva and oral secretions (OS) samples were collected. The concentration of immune markers was estimated using Luminex multiplex assay (Thermo Fisher Scientific, Waltham, MA). For each sample, the concentration of respective immune markers was normalized to total protein present and log-transformed. Median concentrations of immune markers were compared between both types of samples. Intermarker correlation in each sampling method and across sampling methods was evaluated.

Results

There were 90 study participants. Concentrations of immune markers in saliva samples were significantly different from concentrations in OS samples. Oral secretions samples showed higher concentrations of immunoregulatory markers, whereas the saliva samples contained proinflammatory markers in higher concentration.

Conclusion

The immune marker profile in saliva samples is distinct from the immune marker profile in paired OS samples.

Level of Evidence

2b. Laryngoscope, 2017

http://ift.tt/2A7Gmd0

Epistaxis in children and adolescents with hereditary hemorrhagic telangiectasia

Objectives/Hypothesis

Our objective was to describe epistaxis onset and severity in pediatric hereditary hemorrhagic telangiectasia (HHT) patients and study the cumulative incidence of epistaxis by age of onset within each genetic subtype.

Study Design

Retrospective cohort chart review.

Methods

Charts were reviewed of patients age 0 to 18 years with a clinical or genetic diagnosis of HHT who were evaluated at a tertiary multidisciplinary HHT clinic from January 2010 to June 2016. The epistaxis severity score (ESS), a validated tool for assessing epistaxis severity, was used to assess epistaxis. Statistical analyses were conducted on the full HHT cohort as well as subgroups stratified by the HHT causative gene (HHT1 = ENG and HHT2 = ACVRL1).

Results

Sixty-nine pediatric subjects were identified; 60 had HHT confirmed by genetic testing, and nine (from families with known mutations) met published clinical diagnostic criteria alone. Fifty-nine (85%) had onset of epistaxis. The median age of onset of epistaxis was 5 years (interquartile range [IQR]: 2–9 years). The median ESS for the entire cohort was 1.6 (IQR: 0–2.6). The median ESS was higher in HHT1 versus HHT2 (2.3 vs. 1.1, P = .002), and age of epistaxis onset was earlier in HHT1 (3 vs. 5 years, P = .03). Sex and age were not associated with ESS.

Conclusions

Epistaxis may present early in HHT, but is typically mild in the pediatric period. Severity in the pediatric population is worse in patients with HHT1. By recognizing the significance of even mild, infrequent epistaxis in a child with a family history of HHT, and understanding that not all HHT patients have epistaxis during childhood, community providers and otolaryngologist can assist in the early detection of HHT.

Level of Evidence

4 Laryngoscope, 2017

http://ift.tt/2jiBTMw

Perspectives in allergen immunotherapy: 2017 and beyond

Abstract

The Future of the Allergists and Specific Immunotherapy (FASIT) workshop provides a regular platform for global experts from academia, allergy clinics, regulatory authorities and industry to review developments in the field of allergen immunotherapy (AIT). The most recent meeting, held in February 2017, had two main themes: advances in AIT and hot topics in AIT from the regulatory point of view. The first theme covered opportunities for personalised AIT, advances in adjuvants and delivery systems, and the development of new molecules and future vaccines for AIT. Key topics in the second part of the meeting were the effects of the enactment of European Directive 2001/83 on the availability of allergens for therapy and diagnosis across the EU, the challenges of conducting Phase III studies in the field, the future role of allergen exposure chambers in AIT-studies, and specific considerations in performing AIT-studies in the paediatric population.

Finally, the group highlighted the forthcoming EAACI guidelines and their particular importance for the standardisation of practice in the treatment of allergies. This supplement presents a comprehensive insight into those panel discussions and highlights unmet needs and also possible solutions to them for the future.

http://ift.tt/2AaOj1n

Das Ringerohr der etwas anderen Art

Zusammenfassung

Wir berichten über den Fall eines 19-jährigen Mannes mit rezidivierenden, kreisförmigen und groblamellär geschuppten Hautveränderungen. Anamnestisch war der Patient in seiner Freizeit als Ringer tätig. Nach zunächst frustraner antibiotischer Lokaltherapie konnte im Rahmen einer spezifischen dermatologischen Diagnostik eine Tinea corporis gladiatorum gesichert werden. Unter der leitliniengerechten Therapie für Dermatophytosen mittels systemischer Gabe von Fluconazol sowie einer Lokaltherapie mit Ciclopiroxolamin und Ketoconazol konnte eine schnelle Befundbesserung erwirkt werden.

http://ift.tt/2A8jiLj

Internal fit of three-unit fixed dental prostheses produced by computer-aided design/computer-aided manufacturing and the lost-wax metal casting technique assessed using the triple-scan protocol

Suboptimal adaptation of fixed dental prostheses (FDPs) can lead to technical and biological complications. It is unclear if the computer-aided design/computer-aided manufacturing (CAD/CAM) technique improves adaptation of FDPs compared with FDPs made using the lost-wax and metal casting technique. Three-unit FDPs were manufactured by CAD/CAM based on digital impression of a typodont model. The FDPs were made from one of five materials: pre-sintered zirconium dioxide; hot isostatic pressed zirconium dioxide; lithium disilicate glass-ceramic; milled cobalt-chromium; and laser-sintered cobalt-chromium. The FDPs made using the lost-wax and metal casting technique were used as reference. The fit of the FDPs was analysed using the triple-scan method. The fit was evaluated for both single abutments and three-unit FDPs. The average cement space varied between 50 μm and 300 μm. Insignificant differences in internal fit were observed between the CAD/CAM-manufactured FDPs, and none of the FPDs had cement spaces that were statistically significantly different from those of the reference FDP. For all FDPs, the cement space at a marginal band 0.5–1.0 mm from the preparation margin was less than 100 μm. The milled cobalt-chromium FDP had the closest fit. The cement space of FDPs produced using the CAD/CAM technique was similar to that of FDPs produced using the conventional lost-wax and metal casting technique.

http://ift.tt/2zyUnnf

Αρχειοθήκη ιστολογίου

Παρασκευή 24 Νοεμβρίου 2017

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