Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography

Objective: Diagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate. Methods: In this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed. Results: LT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT. Conclusion: This study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%

First-In-Human Study in Cancer Patients Establishing the Feasibility of Oxygen Measurements in Tumors Using Electron Paramagnetic Resonance With the OxyChip

Objective: The overall objective of this clinical study was to validate an implantable oxygen sensor, called the ‘OxyChip’, as a clinically feasible technology that would allow individualized tumor-oxygen assessments in cancer patients prior to and during hypoxia-modification interventions such as hyperoxygen breathing. Methods: Patients with any solid tumor at ≤3-cm depth from the skin-surface scheduled to undergo surgical resection (with or without neoadjuvant therapy) were considered eligible for the study. The OxyChip was implanted in the tumor and subsequently removed during standard-of-care surgery. Partial pressure of oxygen (pO2) at the implant location was assessed using electron paramagnetic resonance (EPR) oximetry. Results: Twenty-three cancer patients underwent OxyChip implantation in their tumors. Six patients received neoadjuvant therapy while the OxyChip was implanted. Median implant duration was 30 days (range 4–128 days). Forty-five successful oxygen measurements were made in 15 patients. Baseline pO2 values were variable with overall median 15.7 mmHg (range 0.6–73.1 mmHg); 33% of the values were below 10 mmHg. After hyperoxygenation, the overall median pO2 was 31.8 mmHg (range 1.5–144.6 mmHg). In 83% of the measurements, there was a statistically significant (p ≤ 0.05) response to hyperoxygenation. Conclusions: Measurement of baseline pO2 and response to hyperoxygenation using EPR oximetry with the OxyChip is clinically feasible in a variety of tumor types. Tumor oxygen at baseline differed significantly among patients. Although most tumors responded to a hyperoxygenation intervention, some were non-responders. These data demonstrated the need for individualized assessment of tumor oxygenation in the context of planned hyperoxygenation interventions to optimize clinical outcomes

Pathophysiology of respiratory failure following acute dichlorvos poisoning in a rodent model

Organophosphate (OP) poisoning causes a cholinergic crisis with a wide range of clinical effects including central apnea, pulmonary bronchoconstriction and secretions, seizures, and muscle weakness. The morbidity and mortality from acute OP poisoning is attributed to respiratory failure but the relative contributions of the central and peripheral effects in producing collapse of the respiratory system are unclear. In this study we used a novel adult rat model of acute OP poisoning to analyze the pathophysiology of acute OP poisoning. We found that poisoning caused rapidly lethal central apnea. In animals sustained with mechanical ventilation, we found that following central apnea there ensued progressive pulmonary insufficiency that was variable in timing and severity. Our findings support the hypothesis that OP poisoning in this animal model causes a sequential two hit insult, with rapid central apnea followed by delayed impairment of pulmonary gas exchange with prominent airway secretions

Vallecular Varix: A Perplexing Cause of Oral Cavity Bleeding

Often discovered only after an extensive work up for hemoptysis and hematemesis, vallecular varices are a rare cause of oral bleeding that increase patient morbidity due to delay of diagnosis. We describe an 89-year-old male who presented with a week of intermittent oral blood production. A vallecular varix was identified on fiberoptic laryngoscopy after studies for hematemesis and hemoptysis had been performed, including negative esophagogastroduodenoscopy and bronchoscopy. Awareness of this pathology and key points in the patient history can direct the clinician toward the correct diagnosis, expediting treatment and limiting invasive diagnostic procedures for pulmonary or gastric etiologies of bleeding

Vallecular Varix: A Perplexing Cause of Oral Cavity Bleeding

Often discovered only after an extensive work up for hemoptysis and hematemesis, vallecular varices are a rare cause of oral bleeding that increase patient morbidity due to delay of diagnosis. We describe an 89-year-old male who presented with a week of intermittent oral blood production. A vallecular varix was identified on fiberoptic laryngoscopy after studies for hematemesis and hemoptysis had been performed, including negative esophagogastroduodenoscopy and bronchoscopy. Awareness of this pathology and key points in the patient history can direct the clinician toward the correct diagnosis, expediting treatment and limiting invasive diagnostic procedures for pulmonary or gastric etiologies of bleeding

Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography

ObjectiveDiagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate.MethodsIn this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed.ResultsLT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT.ConclusionThis study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%

Vallecular Varix: A Perplexing Cause of Oral Cavity Bleeding

Often discovered only after an extensive work up for hemoptysis and hematemesis, vallecular varices are a rare cause of oral bleeding that increase patient morbidity due to delay of diagnosis.We describe an 89-year-old male who presented with a week of intermittent oral blood production. A vallecular varix was identified on fiberoptic laryngoscopy after studies for hematemesis and hemoptysis had been performed, including negative esophagogastroduodenoscopy and bronchoscopy. Awareness of this pathology and key points in the patient history can direct the clinician toward the correct diagnosis, expediting treatment and limiting invasive diagnostic procedures for pulmonary or gastric etiologies of bleeding

Phase resetting of the respiratory oscillator by carotid sinus nerve stimulation in cats

Stimulation of the carotid sinus nerve causes an increase in inspiratory (I) and expiratory (E) neural activities. If central respiratory oscillation is generated by an attractor-cycle process, an increase in its activity can be caused by a centrifugal perturbation of state. We evaluated this hypothesis by comparing the respiratory oscillator's phase responses to carotid sinus nerve stimulations in cats to the phase responses of an attractor-cycle oscillator, the Bonhoeffer-van der Pol (BvP) equations, subjected to centrifugal perturbations.We recorded phrenic activity in seven anaesthetized, vagotomized, glomectomized, paralysed and servo-ventilated cats. Carotid sinus nerve (CSN) stimulation with 0.5–0.8 s electrical pulse trains increased the immediate cycle period and delayed the onset of breaths after stimulation in a highly predictable manner, with the exception that strong stimuli (25 Hz, 0.25–0.90 V) caused unpredictable responses when given at the I-E or the E-I transitions. The resetting plots exhibited focal gaps corresponding to these unpredictable responses, and the size of the gaps increased with increases in the strength of CSN stimulation. Type 0 resetting was not achieved despite the large perturbations in rhythm induced by CSN stimulation.Centrifugal perturbations of the BvP oscillator resulted in phase responses which were similar to those found in the animal experiments. The BvP cycle had two critical phases at which phase resetting was highly irregular and neighbouring state trajectories were highly divergent. The resetting plots had focal gaps that increased in size with increases in the strength of perturbation. The gaps did not represent true discontinuity because at higher computational resolution the resetting plots appeared to be steep but smooth portions of topological Type 1 resetting curves.These studies support the concept that brief carotid sinus nerve stimulations cause a transient outward displacement of the central respiratory state away from its attractor cycle, in contrast to the unidirectional displacements that accompany midbrain reticular or superior laryngeal nerve stimulations. The findings define particular geometrical relationships between oscillatory state trajectories of the rhythm generator and perturbed state trajectories induced by inputs to the oscillator. These relationships provide a framework for developing and testing the validity of neural models of the respiratory oscillator

The submental island flap in head and neck reconstruction: A 10-year experience examining application, oncologic safety, and role of comorbidity

BackgroundWe present our experience on reconstructive versatility and risk of nodal transfer with the submental island flap (SIF). We also examine the role of comorbidity as a predictor of complications.MethodsRetrospective cohort study of patients undergoing SIF over 10-year period. Comorbidity determined using Adult Comorbidity Evaluation 27 index (ACE-27). Univariable/multivariable logistic regressions performed to determine association of these characteristics and rates of major complications.ResultsFifty-eight patients underwent SIF reconstruction, 27 (45%) patients had moderate/severe comorbidity, and 24 (41%) experienced major complication. Multivariable analysis identified ACE-27 scores >2 predictive of major flap complications (OR: 17.38, 95% CI: 1.96–153.74, p = .01) and medical complications (OR: 5.8, 95% CI: 1.11–30.23, p = .037). There were no cases of pathologic nodal transfer.ConclusionThe SIF is a versatile flap and oncologically safe in carefully selected patients. The ACE-27 index is strongly predictive of major postoperative complications.Level of Evidence4We review our experience with the submental island flap (SIF) in head and neck reconstruction examining versatility, oncologic safety, and affect of comorbidity on outcomes. The SIF is a versatile flap and oncologically safe in carefully selected patients. The Adult Comorbidity Evaluation 27 index is strongly predictive of major postoperative complications.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/172326/1/lio2741.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/172326/2/lio2741_am.pd

Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography

Objective: Diagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate. Methods: In this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed. Results: LT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT. Conclusion: This study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%