Radiology quiz case 1. Diagnosis: supernumerary intranasal tooth.
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Adult↗
Biomedical subjects
Kelvin C Lee
Publications and source records attributed to Kelvin C Lee.
Mycosis fungoides: a case of tonsil involvement.
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Adult↗
Randomized, controlled, multisite study of intracapsular tonsillectomy using low-temperature plasma excision.
OBJECTIVE: To determine the efficacy of intracapsular tonsillectomy using low-temperature plasma excision for improving the quality of the postoperative experience and for treating obstructive symptoms through 12 months postoperatively. DESIGN: Prospective, randomized, controlled, single-blind study. SETTING: Multiple private or institutional otolaryngology clinics. PATIENTS: Fifty-five children (aged 3-12 years) with obstructive tonsillar hypertrophy. INTERVENTION: Patients were randomly assigned and blinded to undergo either intracapsular tonsillectomy using low-temperature plasma excision (n = 27) or total tonsillectomy using conventional electrosurgery (n = 28). MAIN OUTCOME MEASURES: Operative data, 14-day recovery variables, and obstructive symptoms were prospectively collected through 12 months. RESULTS: During the first 14 days, significantly fewer children in the intracapsular group reported nausea (P = .01) or lost weight (P = .003). The intracapsular group had a significantly faster resolution of pain (P = .01), had an earlier return to a normal diet (P = .004), ceased taking pain medication sooner (P = .002), and returned to normal activity sooner (P = .04). Postoperatively, the intracapsular group had more residual tonsil tissue than the total tonsillectomy group (P = .002 for the 3- and 12-month visits). However, the incidence of recurring obstructive symptoms, pharyngitis, and antibiotic use was similar in both treatment groups during the 12 months. CONCLUSIONS: Postoperative morbidity normally associated with traditional (total) tonsillectomy was significantly reduced after intracapsular tonsillectomy using low-temperature plasma excision. The residual tonsillar tissue associated with this technique was of no clinical consequence.
Child↗
Sinusitis and fever of unknown origin.
It is relatively uncommon to document sinusitis as a cause of fever with much certainty. Therefore, investigation for sinusitis should be undertaken only after more likely causes have been excluded. and the actions taken should reflect the individual patient's circumstances. Aggressive evaluation and treatment should be geared to minimizing the patient's overall morbidity and to identifying the more aggressive forms of sinusitis and their potential complications.
Biopsy↗
Surgical advances in tonsillectomy: report of a roundtable discussion.
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Consensus↗
Otolaryngologic manifestations of immunodeficiency.
Otolaryngologists are frequently consulted to manage infectious and noninfectious complications of immune deficiency. Although defects of host defense and recurrent or severe infections are the most obvious manifestations of immune deficiency, patients are often at increased risk for autoimmune and malignant disease as well. Knowledge of primary and acquired immune deficiencies will facilitate appropriate identification, treatment, and referral of patients with these defects. When immunodeficiency is known or suspected, it is particularly important to have a high index of suspicion for unusual or severe manifestations of infection, to have a low threshold for obtaining imaging to aid in diagnosis, and to treat infections for longer periods of time with higher doses of antibiotic. Surgery may be required for definitive treatment of infections that do not respond to medical therapy and for management of complications of infectious disease
Antibody Formation↗
The efficacy of anatomically based multilevel surgery for obstructive sleep apnea.
OBJECTIVE: Most reports in the literature focus on the efficacy of a single procedure for obstructive sleep apnea (OSA). We review the overall efficacy of a surgical methodology based on localizing the level of anatomic obstruction for each patient and surgical correction of the nasal, oropharyngeal, or hypopharyngeal obstruction. Study design and setting Retrospective review of cases performed by a single practitioner using a systematic approach to surgery for OSA with preoperative and postoperative sleep studies. RESULTS: Forty-two patients with a respiratory disturbance index (RDI) greater than 15 were included in the study. Surgery involved at least 2 levels of obstruction usually performed in 2 stages. All patients reported symptomatic improvement. Overall, 83.3% (35 of 42) of patients were cured according to the accepted RDI criteria of more than 50% reduction and final RDI of less than 20. All 21 patients with mild OSA (RDI, <29), 73% of patients with moderate OSA (RDI, 30 to 49), and 50% of patients with severe OSA (RDI, >50) were cured. CONCLUSION: The use of an anatomically based methodology in approaching patients with OSA seems to offer a higher efficacy than a single procedure as reported in the literature.
Adolescent↗
Contemporary issues in rhinosinusitis and HIV infection.
The medical issues involving patients infected with HIV continue to evolve dramatically. As they live longer sustained on antiretroviral therapy, their prevalence of acute and chronic sinusitis has increased. The common infectious causes of rhinosinusitis found in the general population are often the culprits in HIV-infected patients. However, as their CD4 counts dip below 200 cells/mm, these patients become susceptible to more opportunistic infections and neoplasms. The diagnostic and therapeutic measures used should reflect the physician's suspicion for these usual causes. The otolaryngologist should manage these patients aggressively because sinusitis can have a significant impact on the patients' quality of life as well as survival. Selected patients with either recurrent or chronic sinusitis may benefit from endoscopic sinus surgery.
AIDS-Related Opportunistic Infections↗
Incidence of complications for subtotal ionized field ablation of the tonsils.
OBJECTIVE: Ionized field ablation, or coblation-assisted subtotal tonsillectomy, has been described as a new alternative technique for the management of tonsillar disease. This study was designed to review the incidence of complications in patients undergoing this procedure. STUDY DESIGN: A 10-surgeon retrospective chart review of the intraoperative and postoperative complications of patients undergoing ionized field ablation subtotal removal of tonsils was performed. Postoperative pain, dietary restrictions, and activity level were not reviewed. RESULTS: Of the 528 patients who underwent ionized field ablation of their tonsils, the incidence of intraoperative and postoperative complications compared favorably with those reported in retrospective studies in the literature for traditional subcapsular tonsillectomy. Significant postoperative bleeding occurred in less than 1%, and only 1 patient required surgical control of bleeding in the operating room. No patients required transfusions of any blood products. CONCLUSIONS: Ionized field ablation subtotal tonsillectomy may offer an alternative to traditional subcapsular tonsillar surgery with a decreased incidence of postoperative complications. Further study is necessary to establish the complication rate of this technique.
Adolescent↗
Irreversible engineering of the multielement-binding antibody 2D12.5 and its complementary ligands.
Engineering the permanent formation of a receptor-ligand complex has a number of potential applications in chemistry and biology, including targeted medical imaging and therapy. Starting from the crystal structure of the rare-earth-DOTA binding antibody 2D12.5 (Corneillie, T. M., Fisher, A. J., and Meares, C. F. (2003) J. Am. Chem. Soc. 125, 15039-15048), we used the site-directed incorporation of cysteine nucleophiles at the periphery of the antibody's binding site, paired with the chemical design of a weakly electrophilic ligand, to produce a receptor-ligand pair that associates efficiently and permanently. Protein residues proximal to the ligand's side chain were identified for engineering cysteine mutants. Fab fragments incorporating a cysteine at position 54, 55, or 56 of the heavy chain (complementarity determining region 2) were designed from the structure and then cloned, expressed in Drosophila S2 cells, and tested for reactivity with mildly electrophilic DOTA-yttrium ligands. All showed permanent binding activity, indicating that there is some tolerance for the location of the reactive mutant on the protein surface near the binding site. The G54C Fab mutant displayed the highest expression levels and permanent binding activity in initial experiments and was produced in high yield for further study. Upon examining the behavior of the G54C mutant with a small set of electrophilic ligands, differences in reactivity were observed which indicated that the substituents near the electrophilic atom can be important determinants of permanent binding. The G54C mutant permanently attaches to Y(3+) complexes of (S)-2-(4-acrylamidobenzyl)-DOTA with a half-time of approximately 13 min at 37 degrees C, making it potentially useful for in vivo pretargeting applications.
Animals↗
Converting weak binders into infinite binders.
Monoclonal antibody 2D12.5 binds DOTA chelates of all the rare earths with K(d) approximately 10(-)(8) M, making it useful for the capture of probe molecules with a variety of properties. To make 2D12.5 even more useful for biological applications, we have engineered a single cysteine residue at position 54 of the heavy chain, a site proximal to the protein's binding site, so that weakly electrophilic metal complexes of (S)-2-(4-acrylamidobenzyl)-DOTA (AABD) may bind and form permanent linkages. At 37 degrees C, pH 7.5, all of the rare earth-AABD complexes bind permanently to the 2D12.5 G54C mutant within 5 min, in yields that correlate with their relative binding affinities. Surprisingly, indium-AABD also binds permanently in >50% yield within 5 min, despite the fact that changing the metal to indium reduces the affinity approximately 100x; even copper-AABD, which has approximately 10 000x lower binding affinity than the rare earths, binds permanently in >70% yield within 2 h. However, acrylamido compounds with no measurable affinity do not bind permanently. The important practical implication is that the G54C mutant of 2D12.5 may be used for applications that include not only the rare earths, but also an unexpected range of other elements as well. This infinite binding system can exhibit selective and permanent attachment with a remarkable range of structurally related ligands, albeit at slower rates as affinities decrease.
Antibodies, Monoclonal↗
Nasal obstruction and sleep-disordered breathing: a study using acoustic rhinometry.
BACKGROUND: The relationship between nasal airway function and sleep-disordered breathing (SDB) remains unclear. Although correction of nasal obstruction can significantly improve nighttime breathing in some patients, nasal obstruction may not play a role in all cases of SDB. An effective method of stratifying these patients is needed. Acoustic rhinometry (AR) is a reliable, noninvasive method of measuring the dimensions of the nasal airway. METHODS: In 44 patients, we performed acoustic rhinometric measurements of nasal airway cross-sectional area, followed by hospital-based polysomnography and nasal continuous positive airway pressure (nCPAP) level titration. We compared anatomic nasal obstruction to perceived nasal obstruction, as well as respiratory distress index and nCPAP titration level, using the Pearson correlation and multiple linear regression analysis within body mass index groups. RESULTS: Perceived nasal obstruction correlated significantly with objective anatomic obstruction as measured by AR (r = 0.45, p < 0.01). For certain subgroup analyses in patients with a body mass index below 25, AR measurements correlated significantly with both nCPAP titration pressure (r = 0.85, p < 0.01) and respiratory distress index (r = 0.67, p = 0,03). CONCLUSION: Nasal airway function may be a significant component of SDB in some patients, perhaps playing a larger role in patients who are not overweight. The best responders to nasal surgery for SDB may be nonoverweight patients with nasal obstruction. AR along with nasal examination may be helpful in the evaluation and treatment of the SDB patient.
Adult↗
Acoustic rhinometry predicts tolerance of nasal continuous positive airway pressure: a pilot study.
BACKGROUND: Nasal continuous positive airway pressure (nCPAP) is usually the first-line intervention for obstructive sleep apnea, but up to 50% of patients are unable to tolerate therapy because of discomfort-usually nasal complaints. No factors have been definitively correlated with nCPAP tolerance, although nasal cross-sectional area has been correlated with the level of CPAP pressure, and nasal surgery improves nCPAP compliance. This study examined the relationship between nasal cross-sectional area and nCPAP tolerance. METHODS: We performed acoustic rhinometry on 34 obstructive sleep apnea patients at the time of the initial sleep study. Patients titrated to nCPAP were interviewed 18 months after starting therapy to determine CPAP tolerance. Demographic, polysomnographic, and nasal cross-sectional area data were compared between CPAP-tolerant and -intolerant patients. RESULTS: Between 13 tolerant and 12 intolerant patients, there were no significant differences in age, gender, body mass index, CPAP level, respiratory disturbance index, or subjective nasal obstruction. Cross-sectional area at the inferior turbinate differed significantly between the two groups (p = 0.03). This remained significant after multivariate analysis for possibly confounding variables. A cross-sectional area cutoff of 0.6 cm2 at the head of the inferior turbinate carried a sensitivity of 75% and specificity of 77% for CPAP intolerance in this patient group. CONCLUSION: Nasal airway obstruction correlated with CPAP tolerance, supporting an important role for the nose in CPAP, and providing a physiological basis for improved CPAP compliance after nasal surgery. Objective nasal evaluation, but not the subjective report of nasal obstruction, may be helpful in the management of these patients.
Adult↗