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Biomedical subjects

M K Wax

Publications and source records attributed to M K Wax.

At least 37 records · Page 2Linked to original sources
PubMed2000

External beam radiation followed by planned neck dissection and brachytherapy for base of tongue squamous cell carcinoma.

BACKGROUND: Surgical resection of tongue base cancer can leave the patient with significant functional deficits. Other therapies, such as external beam radiation followed by neck dissection and radiation implants, have shown equal tumor control with good functional outcome. METHODS: Between March 1991 and July 1999, 12 patients at Oregon Health Sciences University, the Portland Veterans Administration Medical Center and West Virginia University School of Medicine Hospital were treated with external beam radiation followed by neck dissection and Ir192 implants. Two patients had T1 disease, two had T2, five patients had T3 tumors, and three had T4 tumors. Six had N2a necks, three had N2b necks, and three had N2c. Follow-up ranged from 13 months to 8 years. RESULTS: After external beam radiation, five patients had complete response and seven had partial response in the neck without complications. One patient underwent a unilateral radical neck dissection, eight had unilateral selective neck dissections involving levels I to IV, and three had dissections involving levels I to III. One of the five patients who had a complete clinical response in the neck had pathologically positive nodes. One patient had a pulmonary embolus that was treated and had no permanent sequelae. There were three complications from brachytherapy. Two patients had soft tissue necrosis at the primary site and one patient had radionecrosis of the mandible. All healed without further therapy. One patient had persistent disease and underwent a partial glossectomy but died of local disease. Distant metastasis developed in two patients. All others show no evidence of disease and are able to eat a normal diet by mouth. CONCLUSION: This combination of therapies should be considered when treating tongue base cancer.

Aged↗
PubMed2000

Pursestring closure of radial forearm fasciocutaneous donor sites.

BACKGROUND: The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity. MATERIAL AND METHODS: Prospective evaluation of a pursestring closure of radial forearm fasciocutaneous donor sites over a 16-month period. RESULTS: Seventy-one radial forearm free flaps were used. Sixty-seven had a pursestring closure of the donor site. After flap elevation the mean size of the defect was 61 cm2 (range, 28-140 cm2). Pursestring closure decreased the mean of the defect to 34 cm2 (range, 10-104 cm2) (P <.0001). Defect size was decreased by a mean of 44.5% (range, 24.5%-66.7%) (P <.0001). COMPLICATIONS: The rate of skin graft loss (>25%) (9% of patients) was less than that reported in the literature. No patient required a second surgical procedure. Neural morbidity was equal in both groups. Cosmesis was much improved. CONCLUSIONS: Pursestring closure allowed for a significantly decreased donor defect, associated with better cosmesis and less skin graft loss.

Forearm↗
PubMed1999

Effect of clamp versus anastomotic-induced ischemia on critical ischemic time and survival of rat epigastric fasciocutaneous flap.

BACKGROUND: There are many models used to explore ischemic-related phenomena. The rat epigastric fasciocutaneous flap model is the one most commonly used. Critical ischemic time is the maximum ischemic insult that tissue can undergo and still remain viable. Experimentally, ischemia is induced either by clamping the vascular pedicle or by dividing the pedicle then performing microvascular arterial and venous anastomosis. We sought to determine what effect the different methods of inducing ischemia have on the critical primary ischemic time and, thus, flap survival. METHODS: A right 3 cm x 6 cm groin flap based on the inferior epigastric vessels was raised in each rat. Ischemic times of 4, 6, 8, or 10 hours were induced either by placing temporary occlusion clamps on each vessel of the vascular pedicle (island pedicle group) or by ligation and division of the pedicle with subsequent microvascular anastomosis (free flap group). Survival was assessed at 7 days. RESULTS: The primary ischemic time at which one half of free flaps are predicted to die was calculated to be 7.60 hours, compared with 6.09 hours for the island pedicle flaps (p<.05). CONCLUSIONS: Fasciocutaneous flaps undergoing ligation and anastomosis are more resistant to ischemia than are those undergoing clamping of the pedicle. Possible etiologic factors responsible for this experimental finding are discussed.

Anastomosis, Surgical↗
PubMed1999

Atypical presentations of actinomycosis.

BACKGROUND: Actinomycotic infections of the cervicofacial region are uncommon. Most major medical centers report approximately one case per year. Presenting clinical manifestations are confusing because they often mimic other disease processes. Diagnosis may be difficult due to a general lack of familiarity with the disease and the fastidious nature of the organism in culture. The cervicofacial manifestations of actinomycosis are varied, and a high index of suspicion is required to make an accurate and timely diagnosis. METHODS: Retrospective chart review with the presentation of four unusual cases of actinomycosis were performed. RESULTS: Two patients were initially seen with dysphagia from a tongue base mass. The third patient was initially seen with a 3-week history of worsening hoarseness and stridor. Examination revealed an ulcerative lesion of the left hemilarynx and pyriform sinus. All three patients were thought to have a neoplastic process. Diagnosis was made on histologic examination of a tissue biopsy. The fourth patient was initially seen with a buccal space mass that was draining externally. Culture of the purulent drainage revealed Actinomyces. In all four cases, symptoms resolved after appropriate antimicrobial therapy. CONCLUSIONS: Actinomycosis of the head and neck, although rare, is an important entity to the otolaryngologist. A confusing clinical presentation combined with the fastidious nature of the organism make for a difficult diagnosis. A high index of suspicion is required to make an accurate diagnosis and institute the appropriate antibiotic therapy.

Actinomycosis, Cervicofacial↗
PubMed1999

Management paradigms for posterior epistaxis: A comparison of costs and complications.

OBJECTIVES: Posterior epistaxis is a common otolaryngologic emergency. Management is controversial because of the many treatment options available. These options vary in efficacy, rates of complications, and cost. Posterior nasal packing is the medical management most frequently used to control posterior epistaxis. It is associated with major complications, including stroke, myocardial infarction, arrhythmias, and death. Because of these potential complications, many otolaryngologists monitor patients with posterior nasal packing in the intensive care unit (ICU). However, the level of care used to monitor these patients is variable, and standards have not been established. METHODS: From 1991 to 1997, 46 patients had posterior nasal packing placed to control epistaxis. Management, complications, and hospital charges were analyzed. RESULTS: Six patients (13%) were admitted to the ICU, 2 (4%) were admitted for telemetry monitoring, and 38 (83%) were sent to the ENT ward for continuous pulse oximetry. Four major complications occurred (1 episode of syncope [emergency department], 2 arrhythmias [ICU], and 1 death [hospice]). Twenty-six patients were treated with posterior packing in the ENT ward, at a mean cost of $2988. Fourteen patients underwent intervention (5 ligations, 6 endoscopic cauterizations, and 3 angiograms), with a mean cost of $5482. Six patients spent time in the ICU, with a mean cost of $8242. Patients treated in the ENT ward had significantly lower costs than those undergoing intervention (P = 0.017) or those admitted to the ICU (P = 0.020). CONCLUSION: We propose that most patients with posterior epistaxis can be treated in specialized ENT wards. This can be done without increasing complications and with significantly decreased costs.

Adult↗
PubMed1999

Management of the N0 neck during salvage laryngectomy.

BACKGROUND: Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated. OBJECTIVE: Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy. STUDY DESIGN: Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection. METHODS: Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y). RESULTS: The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries). CONCLUSIONS: Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.

Adult↗
PubMed1999

Effects of acute thyroxin depletion on hearing in humans.

OBJECTIVE: To study the physiologic effect of acute thyroid hormone depletion on hearing and the function of outer hair cells. DESIGN: Audiologic and otoacoustic emission testing of subjects undergoing total thyroidectomy before surgery and up to 6 weeks after surgery. Magnitude of thyroxin depletion monitored by serum thyroid-stimulating hormone levels. SETTING: Hearing research laboratory at a state university. SUBJECTS: Ten patients undergoing total thyroidectomy. MAIN OUTCOME MEASURES: Detection of hearing loss on audiogram and decrease or disappearance of otoacoustic emissions as a result of acute thyroxin depletion. RESULTS: No significant changes in the audiogram and otoacoustic emission configurations were detected, although thyroid-stimulating hormone levels became elevated after total thyroidectomy. CONCLUSION: Although thyroid hormone is thought to play a role in the physiology of hearing in humans, no deleterious effects on hearing can be identified up to 6 weeks after thyroxin depletion.

Adult↗
PubMed1999

Effect of photodynamic therapy on the critical primary ischemic time of fasciocutaneous flaps.

BACKGROUND: Photodynamic therapy (PDT) may be used as an adjuvant intraoperative therapy to improve locoregional control. PDT has been shown to delay wound healing. This raises concern about PDTs effect on survival of fasciocutaneous flaps. OBJECTIVE: Evaluate the effect of 1) PDT on the critical ischemic time in a rat fasciocutaneous flap model and 2) photosensitizer activation by the surgical light source. DESIGN: A fasciocutaneous flap, based on the left inferior epigastric vessels, was used. Ischemic times of 2, 4, 6, 8, 10, and 12 hours were induced by clamping the vascular pedicle. Animals were randomly divided into five groups: ischemia only, group I; light treatment to wound bed, group II; Photofrin before surgery with the flap elevated without a fiber optic head light, group III, or with a headlight, group IV; Photofrin prior to surgery with light treatment to the wound bed, group V. Flap survival was assessed on postoperative day 7. RESULTS: The critical primary ischemic time of group V (PDT) was significantly less (P < .05) than groups I, II, III, and IV. There was no statistical difference in the critical primary ischemic time when a fiber optic headlight was used (group III vs. group IV). CONCLUSION: Intraoperative PDT significantly reduces the critical primary ischemic time of the rat fasciocutaneous flap. White light illumination of the operative field does not result in photosensitizer activation and has no effect on the critical primary ischemic time.

Animals↗
PubMed1999

Management of tracheostomal stenosis.

BACKGROUND: Tracheostomal stenosis following laryngectomy is a distressing complication with major effects on patient rehabilitation. Management ranges from stenting with a prosthetic device to surgical revision. The goal is a widely patent stoma that is amenable to tracheoesophageal puncture. OBJECTIVE: Review the long-term results of different methods of tracheostomal revision. METHODS: Review of 43 patients with symptomatic tracheostomal stenosis. End point was ability to function with no artificial stenting of their stoma. RESULTS: Forty-three patients underwent 55 revisions. The male-to-female ratio was 1.3:1.0. The age range was from 38 to 81 years (mean age, 59.5 y). Median time to revision was 11 months following the initial surgical procedure (range, 1-150 mo). Thirty-three patients underwent one revision; eight patients, two revisions; and two patients, three revisions. In 40 of 43 patients (93%) revision was successful. Of the last 21 patients who underwent revision, 18 had tracheoesophageal punctures placed. Fifteen developed excellent tracheoesophageal speech. The initial rates of success for these procedures were as follows: advancement flaps, 8 of 9; Z-plasty, 13 of 15; V-Y inset, 8 of 8; other procedures, 2 of 4; and dilation, 2 of 7 (P < .05 for dilation vs. all others). The ultimate success rates for these procedures were as follows: advancement flaps, 8 of 11; Z-plasty, 15 of 18; V-Y inset, 12 of 13; other procedures, 3 of 6; and dilation, 2 of 7. Other procedures and dilation were inferior (P < .05) compared with advancement flap, Z-plasty, and V-Y insets. CONCLUSION: Tracheostomal stenosis can be successfully managed in a multitude of ways.

Female↗
PubMed1998

Relationship between tympanic membrane perforations and retained ventilation tubes.

OBJECTIVES: To determine the effects of prolonged ventilation tube retention on tympanic membrane healing and the efficacy of patching procedures used concomitantly at the time of tube removal. DESIGN: Retrospective chart review. SETTING: Tertiary referral academic institution. PATIENTS: Seventy-six patients aged 12 years and younger, with a total of 99 ears identified from January 1989 to December 1994. All patients underwent ventilation tube removal for prolonged tube retention or infection unresponsive to medical management. A minimum of 6 months of follow-up was required for inclusion. INTERVENTION: Ventilation tube removal under general anesthesia, with or without concomitant patching. OUTCOME MEASURES: All medical charts were reviewed for age, sex, indications for tube removal, tube retention time, type of patch used (if any), type of tube, outcome after removal, other medical problems, and previous surgical history. RESULTS: The perforation rate was significantly higher in children with tubes retained beyond 36 months (P=.02). History of previous adenoidectomy predicted poor outcome, with a rate of 47% vs 17% in patients with no such history (P=.002). Patching did not improve healing. No other patient factors significantly influenced the perforation rate. CONCLUSIONS: Ventilation tube retention longer than 36 months resulted in an increased perforation rate after surgical removal. Paper patching at the time of tube removal does not improve healing. Prospective studies are needed to confirm these findings and to determine the efficacy of other patching techniques.

Child↗
PubMed1998

The difficult airway: cardiopulmonary bypass--the ultimate solution.

BACKGROUND: Large, compressive thyroid masses are usually removed as an elective procedure. Rarely is a patient's condition allowed to progress to severe respiratory distress before surgical intervention is recommended. When allowed to progress, management of the airway can be problematic. METHODS: A case report of a patient with a neglected thyroid lymphoma is presented. RESULTS: The natural progression of the disease, leading to impending airway collapse, necessitated emergency management of the airway. Due to supraglottic edema and a large neck mass, traditional methods of securing the airway were not feasible. Initiation of femoral-femoral cardiopulmonary bypass, under local anesthesia, ensured adequate oxygenation and allowed a controlled tracheotomy to be performed. CONCLUSIONS: The result obtained suggests that this approach provides a safe solution for airway control when intubation or a surgically created airway is either unsuccessful or too hazardous.

Aged↗
PubMed1998

Role of antral puncture in the treatment of sinusitis in the intensive care unit.

OBJECTIVE: The objective of this study was to determine whether maxillary sinus puncture caused an alteration in antibiotic treatment and thus affected the outcome of sinusitis in the intensive care unit. STUDY DESIGN: A retrospective review was done of cases of maxillary sinus puncture between 1991 and 1994. RESULTS: Forty-two patients were identified. All patients had findings suggestive of sinusitis on plain sinus films or CT scans of the sinuses. Twenty-five punctures (60%) recovered pus, of which 80% grew organisms. Fourteen patients (33%) had a negative lavage, and 12% of these samples grew organisms (p = 0.001). Sixty-eight percent of the cultures identified a single organism compared with 32% with multiple organisms. Gram-negative organisms were found most commonly, followed by anaerobes. In 57% of the cases antibiotic therapy was changed. In 77% of the cases the change was directed by the culture result and in 35% the therapy was changed despite a negative culture result (p = 0.002). Resolution of symptoms occurred in 83% of patients who had antibiotics changed whereas with no change in antibiotics only 42% had resolution (p = 0.001). CONCLUSION: A sinus puncture seems to be helpful in patients with fever and positive findings on sinus films. If pus is obtained by maxillary puncture, a positive culture may be found in 80% of the cases. Changes in antibiotic regimen on the basis of culture findings seem to give a better outcome.

Adult↗
PubMed1998

Outcome and changing cause of unilateral vocal cord paralysis.

Unilateral vocal cord paralysis (UVCP) is relatively common, and previously, thyroidectomy used to be the leading cause. We retrospectively reviewed 98 cases of UVCP. The left vocal cord was involved in 70% of the cases and the right vocal cord in 30%. The cause was neoplastic in 32%, surgical in 30%, idiopathic in 16%, traumatic in 11%, central in 8%, and infectious in 3% of the cases. Only 4 cases were the result of thyroid surgery. Evaluation consisted of a review of the history, a physical examination, and computerized scanning or magnetic resonance imaging, as needed. The functional recovery rate as related to the cause was as follows: surgery 31%, idiopathic 19%, traumatic 18%, and neoplastic 0%. Thirty-five percent of patients required medialization laryngoplasty or Teflon injection. Lung and skull base tumors and their surgical treatment are the most common causes of UVCP.

Adolescent↗
PubMed1998

Positron emission tomography in the evaluation of the N0 neck.

The presence of cervical lymph node metastasis in patients with head and neck cancer is associated with an unfavorable prognosis. Reports vary as to whether various conventional radiographic studies, such as computed tomography (CT) and magnetic resonance imaging, confer an advantage over physical examination in the patient without clinical findings of cervical metastasis (N0). Positron emission tomography (PET) is a functional imaging modality that has recently been used for head and neck neoplasms. The use of PET in the evaluation of the N0-staged neck in 14 consecutive patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract is reported. Seven patients (50%) undergoing 13 neck dissections had pathologic evidence of disease. PET scans were positive in five patients with pathologically confirmed cervical metastasis. PET scans were negative in seven patients (11 neck dissections) with no pathologic evidence of disease. PET scans were positive for unilateral cervical metastasis in two of three patients with involvement of a single lymph node. PET scans were positive in two of three patients with more than two lymph nodes involved. PET had an accuracy of 100% in the eight patients with SCC of the oral cavity. In patients with oropharyngeal or hypopharyngeal carcinoma PET localized cervical metastasis in two of four patients with neck metastasis. In the patient with an N0-staged neck on clinical examination, PET was found to have an overall sensitivity of 78%, specificity of 100%, positive predictive value of 100%, negative predictive value of 88%, and accuracy of 92%. CT demonstrated sensitivity of 57%, specificity of 90%, positive predictive value of 80%, negative predictive value of 75%, and accuracy of 76%. PET showed a trend in increased accuracy (P = 0.11) over CT. PET appears to be a promising diagnostic aid that may be applied when evaluating the N0-staged neck, especially for SCC of the oral cavity.

Carcinoma, Squamous Cell↗
PubMed1998

Significance of unilateral submandibular gland excision on salivary flow in noncancer patients.

OBJECTIVES/HYPOTHESIS: Normal salivary flow is important for maintaining good oral hygiene. Lack of normal flow predisposes to an increased incidence of dental caries and symptomatic xerostomia. The submandibular glands are responsible for 70% of resting salivary flow. Removal of the submandibular gland is most commonly performed for sialolithiasis, chronic sialoadenitis, or as part of a neck dissection. The effect of unilateral gland resection for benign disease on resting salivary flow has not been well examined in the literature. STUDY DESIGN: Case controlled study involving patients who had undergone a unilateral submandibular gland resection matched with normal control subjects. METHOD: Stimulated and unstimulated salivary flow rates in surgical and control subjects were measured in a controlled setting. RESULTS: Unstimulated salivary flow rates were 0.805 mL/min in the control group and 0.405 mL/min in the surgical group (P = .01). Stimulated salivary flow rates were not significantly different between the two groups (P > .05). Fifty-seven percent of patients in the surgical group and 14% in the control group had xerostomia (P < .05). CONCLUSION: Unilateral submandibular gland excision results in a decreased rate of resting salivary flow and an increase in subjective xerostomia.

Adult↗
PubMed1998

Neck dissection with simultaneous carotid endarterectomy.

BACKGROUND: Patients with metastatic neck disease from upper aerodigestive tract carcinomas have an extensive history of tobacco and alcohol abuse. These patients are predisposed to develop atherosclerotic vascular disease. OBJECTIVE: An increased incidence and severity of carotid stenosis in patients receiving radiotherapy for head and neck cancers is known. Management of patients with severe carotid stenosis who require surgical treatment of their neck disease has not been described. The authors describe our experience with simultaneous carotid endarterectomy and neck dissection. STUDY DESIGN: Prospective data collection. METHODS: From 1991 to 1997 at West Virginia University Hospitals, Morgantown, West Virginia, and State University of New York (SUNY) at Buffalo, three patients with severe carotid stenosis required surgery for metastatic neck disease. Preoperative evaluation revealed a bilateral carotid stenosis greater than 90% in all patients. All patients underwent modified radical neck dissections and simultaneous carotid endarterectomies with saphenous vein grafting. Two patients, one undergoing partial pharyngectomy and laryngectomy and the other a laryngectomy and neck dissection, had coverage of the carotid artery with the myogenous component of a pectoral major graft. One patient had only a neck dissection. RESULTS: Two patients healed with no local morbidity, no neck recurrence, and a patent carotid artery by Doppler. No strokes were encountered. One patient died of a myocardial infarction. CONCLUSION: Severe carotid stenosis that requires revascularization may have endarterectomy performed simultaneously with treatment of head and neck primary with no increase in morbidity.

Aged↗
PubMed1998

Tracheostomal stenosis revision with simultaneous tracheoesophageal puncture.

OBJECTIVES/HYPOTHESIS: Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature. STUDY DESIGN: Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996. METHODS: Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y). RESULTS: All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications. CONCLUSIONS: Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

Esophagus↗