Publications by authors named "Demetri Arnaoutakis"

23 Publications

  • Page 1 of 1

Experience harvesting costal cartilage under IV sedation.

Am J Otolaryngol 2020 Jul - Aug;41(4):102511. Epub 2020 Apr 30.

Lasky Clinic, Beverly Hills, CA, United States of America. Electronic address:

Importance: While numerous techniques for costal cartilage harvesting have been described, one consistency in the published literature is that the procedure is performed under general anesthesia. This is the first report to offer IV sedation as a safe alternative to general inhalational anesthesia in cases involving costal cartilage harvesting.

Objective: To determine the feasibility and safety of costal cartilage harvest with IV sedation.

Design: A retrospective chart review was performed of 116 rhinoplasty patients who underwent harvest of costal cartilage grafts under IV sedation from 2005 to 2019.

Setting: Private practice of senior author (AF) at Lasky Clinical Surgical Center.

Participants: Consecutive patients who underwent cosmetic and/or functional rhinoplasty.

Main Outcome & Measures: The number of cases involving a pneumothorax, size of the pleural injury, radiographic findings, repair technique and treatment for pneumothorax were all recorded.

Results: There were 7 cases involving a pleural tear (size range 3-8 mm) during costal cartilage harvest and each of these was repaired intra-operatively. All 7 patients remained clinically stable in recovery room on 2 L of oxygen. Although clinically stable, one patient had radiologic evidence of a pneumothorax of 50%, and thus she was transferred to a hospital for placement of a Heimlich tube with overnight observation.

Conclusions And Relevance: Although plenural tears can be attributed to surgical technique rather than the type of anesthesia, these cases do provide valuable insight to the fact that successful management of such complications can be accomplished without the need for general anesthesia.
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http://dx.doi.org/10.1016/j.amjoto.2020.102511DOI Listing
November 2020

Surgical and Nonsurgical Techniques in Forehead Rejuvenation.

Facial Plast Surg 2018 Oct 8;34(5):466-473. Epub 2018 Oct 8.

Division of Facial Plastic Surgery, Advanced Facial Plastic Surgery Center, Dallas, Texas.

The periorbital and forehead regions are among the most expressive parts of the face. A thorough understanding of the complex facial anatomy and aesthetic norms are essential when evaluating and treating a patient for facial brow rejuvenation. Not only will knowledge of the anatomy enhance facial injection and surgical outcomes, but will also diminish potential complications. Combining nonsurgical and surgical techniques, including laser and skin rejuvenation, can yield the most natural and effective aesthetic brow improvements.
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http://dx.doi.org/10.1055/s-0038-1669990DOI Listing
October 2018

Endoscopic Transcanal Transpromontorial Approach for Vestibular Schwannoma Resection: A Case Series.

Otol Neurotol 2017 12;38(10):e490-e494

*Department of Otolaryngology-Head and Neck Surgery †Department of Neurosurgery, University of Texas, Southwestern Medical Center, Dallas, Texas ‡Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee.

Objective: To demonstrate successful surgical management of vestibular schwannomas via an exclusively endoscopic transcanal transpromontorial approach (EETTA).

Patients: Four patients with vestibular schwannomas.

Interventions: Surgical excision via EETTA.

Main Outcomes: Technique refinements, tumor access, complete tumor removal, and patient morbidity.

Results: Three tumors were Koos grade I and one tumor was Koos grade II. All ears had non-serviceable hearing prior to surgery. The EETTA enabled access to the internal auditory canal and porus acousticus as well as limited access to the cerebellopontine angle. Gross total tumor resection was achieved in all cases. There were no intraoperative or postoperative complications and the mean hospital duration was 2.8 days. After a mean follow-up of 5.0 months, all cases had a good facial nerve outcome.

Conclusions: The EETTA can be successfully used for the management of small vestibular schwannomas in ears without serviceable hearing. Additional studies are needed to fully elucidate the risk-benefit profile of this minimally invasive approach.
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http://dx.doi.org/10.1097/MAO.0000000000001588DOI Listing
December 2017

Cranioplasty Using a Mixture of Biologic and Nonbiologic Agents.

JAMA Facial Plast Surg 2018 Jan;20(1):9-13

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Importance: A surgeon faces challenges with cranioplasty techniques to achieve a successful result with relatively few complications.

Objective: To describe a unique technique for incorporating both biologic autologous bone and nonbiologic allograft materials for defect coverage in cranioplasty with favorable outcomes and low occurrence of complications.

Design, Setting, And Participants: A retrospective medical records review of all 26 patients who underwent primary cranioplasty procedure with a modified technique between January 2011 and December 2015 at a high-volume head and neck oncologic reconstructive practice was conducted; data analysis was also performed during that period. After several years of experience with traditional cranioplasty maneuvers, the modified technique has evolved to incorporate both autologous bone grafts and alloplastic materials in the formation of a shapeable on-lay material. Data were collected on demographics, need for cranioplasty, materials used, outcomes, and risk factors.

Main Outcomes And Measures: Rates of infection, hematoma, flap loss or resorption, cerebrospinal fluid leak, hardware exposure or malfunction, and repeated reconstruction.

Results: Of the 26 patients, 21 (81%) were men; mean (SD) age was 65.8 (14.3) years. Eight (31%) patients had a history of diabetes, 4 (15%) patients were receiving immunosuppressive drugs, and 5 (19%) patients were active smokers at the time of surgery. Neoplasia was the most common cause of the calvarial defect seen, responsible for 20 of 28 (71%) operative defects and necessitated procedures. All but 1 patient achieved successful mineralization following primary cranioplasty with the modified technique; this success was verified based on physical examination and follow-up imaging. Complications were rare and involved only 3 patients who developed postoperative infection; 1 (4%) of these patients lost the integrity of the cranioplasty. Thus, the rate of infection was 11% and loss rate was 4%. Preoperative and postoperative radiotherapy appeared to have no bearing on graft survival.

Conclusions And Relevance: The results using a unique technique for incorporating both biologic autologous bone and nonbiologic allograft materials for defect coverage in cranioplasty are favorable, with satisfactory aesthetic outcomes and limited postoperative complications.

Level Of Evidence: 4.
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http://dx.doi.org/10.1001/jamafacial.2017.0437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833661PMC
January 2018

Osseointegrated Implants and Prosthetic Reconstruction Following Skull Base Surgery.

Semin Plast Surg 2017 Nov 25;31(4):214-221. Epub 2017 Oct 25.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Rehabilitation following ablative skull base surgery remains a challenging task, given the complexity of the anatomical region, despite the recent advances in reconstructive surgery. Remnant defects following resection of skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction, including local rotational muscle flaps, pedicled flaps with skin paddle, or even free tissue transfer. However, not all patients are appropriate surgical candidates and therefore may instead benefit from nonsurgical options for functional and aesthetic restoration. Osseointegrated implants and biocompatible prostheses provide a viable alternative for such a patient population. The purpose of this review serves to highlight current options for prosthetic rehabilitation of skull base defects and describe their indications, advantages, and disadvantages.
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http://dx.doi.org/10.1055/s-0037-1607201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5656447PMC
November 2017

Locoregional and Microvascular Free Tissue Reconstruction of the Lateral Skull Base.

Semin Plast Surg 2017 Nov 25;31(4):197-202. Epub 2017 Oct 25.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

The goals of reconstruction following any oncologic extirpation are preservation of function, restoration of cosmesis, and avoidance of morbidity. Anatomically, the lateral skull base is complex and conceptually intricate due to its three-dimensional morphology. The temporal bone articulates with five other cranial bones and forms many sutures and foramina through which pass critical neural and vascular structures. Remnant defects following resection of lateral skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction including local rotational muscle flaps, pedicled flaps with skin paddle, or free tissue transfer. In this review, the advantages and disadvantages of each reconstructive method will be discussed as well as their potential complications.
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http://dx.doi.org/10.1055/s-0037-1606556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5656443PMC
November 2017

Treatment Deintensification for Human Papillomavirus-Associated Oropharyngeal Cancer.

Ann Surg Oncol 2017 Nov 10;24(12):3463-3465. Epub 2017 Aug 10.

Division of Head & Neck Cancer, Department of Otolaryngology, Head & Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9035, USA.

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http://dx.doi.org/10.1245/s10434-017-6045-6DOI Listing
November 2017

Endoscopic Lateral Cartilage Graft Tympanoplasty.

Otolaryngol Head Neck Surg 2017 10 6;157(4):683-689. Epub 2017 Jun 6.

1 Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Objective To describe a novel technique for lateral graft tympanoplasty. Study Design Case series with chart review. Setting Tertiary care university hospital. Subjects and Methods Pediatric and adult patients with tympanic membrane perforations deemed unfavorable for a medial graft technique due to the perforation characteristics or myringitis. Results Between 2014 and 2016, 34 ears from 31 patients underwent a transcanal endoscopic lateral cartilage graft tympanoplasty. The mean age was 24.4 years (range, 6-71 years), and 22 patients (65%) were younger than 18 years. All patients had tympanic membrane perforations. Eighteen patients (53%) had total or near-total perforations, leaving a minimal anterior remnant, and 16 patients (47%) had extensive myringitis. A bisected tragal cartilage-perichondrium shield graft was used in 33 patients (97%). The mean (SD) follow-up length was 9.8 (5.7) months. Initial perforation closure rate was 88.2% (30/34). Three of the persistent perforations underwent a revision endoscopic medial graft tympanoplasty with successful closure, leaving a final closure rate of 97.1% (33/34). Five patients (15%) required topical therapy for postoperative myringitis. Mean (SD) pure-tone average and air-bone gap significantly improved by 11.5 (10.7) dB ( P < .001) and 11.4 (10.6) dB ( P < .001), respectively. Twenty-seven patients (79%) closed their air-bone gap within 20 dB. Conclusion Transcanal endoscopic lateral cartilage graft tympanoplasty is feasible, and initial data support favorable outcomes. Further data are necessary for evaluation of long-term results and efficacy comparisons.
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http://dx.doi.org/10.1177/0194599817709436DOI Listing
October 2017

Zika Virus-What the Otolaryngologist Should Know: A Review.

JAMA Otolaryngol Head Neck Surg 2017 01;143(1):81-84

Department of Otolaryngology-Head and Neck Surgery, University of South Florida College of Medicine, Tampa.

Importance: Initially discovered in 1947, Zika virus infection received little notoriety as a tropical disease until 2015 when an outbreak of microcephaly cases was reported in Brazil. Zika is a single-stranded RNA arbovirus of the Flaviviridae family. The primary source of infection in humans stems from Aedes aegypti mosquito bites but can also occur through sexual, blood, and perinatal transmission. With expectations that 3 to 4 million people across the Americas will be infected over the next year, the World Health Organization has declared this event a Public Health Emergency of International Concern.

Observations: Although acute Zika virus infection is typically mild and self-limited, researchers have demonstrated serious neurologic complications associated with it such as microcephaly and Guillain-Barre syndrome. Otolaryngologists should be aware of head and neck manifestations which include conjunctivitis, retro-orbital pain, cephalgia, and odynophagia. The Centers for Disease Control and Prevention have developed specific molecular and serologic testing protocols and algorithms for follow-up care of suspected cases. Currently, the mainstay of management is conservative care while researchers attempt to develop a vaccine. Strategies to contain the Zika virus include vector control, travel restriction for women who are pregnant or trying to become pregnant, and avoidance of mosquito bites in endemic regions of the world.

Conclusions And Revelance: The future outlook regarding the current Zika virus outbreak in the Americas remains uncertain. What is certain is our need to promptly and efficiently address research gaps in our understanding of clinical outcomes from infection and environmental factors that influence emergence meanwhile improving diagnostic, therapeutic, and preventive measures against the disease.
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http://dx.doi.org/10.1001/jamaoto.2016.3427DOI Listing
January 2017

Use of Giant Bilobed Flap for Advanced Head and Neck Defects.

Facial Plast Surg 2016 Jun 1;32(3):320-4. Epub 2016 Jun 1.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

This article aims to review the use of giant bilobed flaps in the reconstruction of various large defects within the head and neck. A single case series study with chart review was performed. Various facial, neck, and mentum defects were documented, and closure was accomplished through a variety of medially and laterally based giant bilobed flaps. Preoperative and postoperative photography, as well as intraoperative planning, was performed. A total of 23 patients were able to achieve closure of facial, head, and neck defects with single-stage closure through the use of a giant bilobed flap. No tissue expanders, free tissue transfers, or skin grafts were required to achieve final closure, with acceptable cosmetic and functional results. Bilobed-shaped flaps allow for local tissue transfer in regions of otherwise limited tissue laxity and mobility, classically designed and utilized in the region of the nose. We describe its applicability to closure of large head and neck defects that may otherwise require free tissue transfer or the use of tissue expanders.
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http://dx.doi.org/10.1055/s-0036-1571808DOI Listing
June 2016

Sinonasal Phosphaturic Mesenchymal Tumor: A Rare and Misinterpreted Entity.

J Neurol Surg Rep 2015 Nov 21;76(2):e233-8. Epub 2015 Aug 21.

Department of Otolaryngology-Head and Neck Surgery, University of Florida College of Medicine, Jacksonville, Florida, United States.

Objectives Oncogenic osteomalacia is a paraneoplastic syndrome in which the tumor secretes a peptide-like hormone, fibroblast growth factor, resulting in urinary loss of phosphates. Methods We present the case of a 50-year-old woman with a benign phosphaturic mesenchymal tumor (PMT) involving the ethmoid sinus with obstruction of the ostiomeatal complex causing unilateral nasal airway obstruction. Results The tumor was initially thought to be an esthesioneuroblastoma based on primary pathology interpretation and on clinical and radiographic appearance. However, a benign PMT was later confirmed by further testing. Conclusion The tumor was removed entirely by the endoscopic transnasal approach, leading to a full resolution of symptoms.
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http://dx.doi.org/10.1055/s-0035-1562852DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4648724PMC
November 2015

Facial nerve trauma: evaluation and considerations in management.

Craniomaxillofac Trauma Reconstr 2015 Mar;8(1):1-13

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

The management of facial paralysis continues to evolve. Understanding the facial nerve anatomy and the different methods of evaluating the degree of facial nerve injury are crucial for successful management. When the facial nerve is transected, direct coaptation leads to the best outcome, followed by interpositional nerve grafting. In cases where motor end plates are still intact but a primary repair or graft is not feasible, a nerve transfer should be employed. When complete muscle atrophy has occurred, regional muscle transfer or free flap reconstruction is an option. When dynamic reanimation cannot be undertaken, static procedures offer some benefit. Adjunctive tools such as botulinum toxin injection and biofeedback can be helpful. Several new treatment modalities lie on the horizon which hold potential to alter the current treatment algorithm.
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http://dx.doi.org/10.1055/s-0034-1372522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329040PMC
March 2015

Pharyngocutaneous fistula after total laryngectomy: a single-institution experience, 2001-2012.

Am J Otolaryngol 2015 Jan-Feb;36(1):24-31. Epub 2014 Sep 2.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, 601 N. Caroline Street, 6th floor, Baltimore, MD, United States; Milton J. Dance Jr. Head and Neck Cancer Center, Greater Baltimore Medical Center, 6569 N. Charles Street, Baltimore, MD, United States.

Purpose: The purpose of this study was to determine the incidence of and risk factors for pharyngocutaneous fistula in patients undergoing total laryngectomy at a single institution.

Materials And Methods: The records of 59 patients undergoing primary or salvage total laryngectomy at our institution from 2001 to 2012 were retrospectively reviewed. Data collected included patient, tumor and treatment characteristics, and surgical technique. Risk factors were analyzed for association with pharyngocutaneous fistula formation.

Results: Twenty patients (34%) developed fistulas. Preoperative tracheostomy (OR 4.1; 95% CI 1.3-13 [p=0.02]) and low postoperative hemoglobin (OR 9.1; 95% CI 1.1-78 [p=0.04]) were associated with fistula development. Regarding surgical technique, primary sutured closure of the total laryngectomy defect had the lowest fistula rate (11%). In comparison, primary stapled closure and pectoralis onlay flap over primary closure had nonsignificantly increased fistula rates (43%, OR 6.0; 95% CI 1.0-37.3 [p=0.06] and 25%, OR 2.7; 95% CI 0.4-23.9 [p=0.38], respectively). Pectoralis flap incorporated into the suture line had a significantly increased fistula rate (50%, OR 7.1; 95% CI 1.4-46 [p=0.02]). After stratification for salvage status, patient comorbidities were associated with fistula in non-salvage cases whereas disease-related characteristics were associated with fistula in salvage cases. Fistula development was associated with increased length of hospital stay (p<0.001) and increased time before oral diet initiation (p<0.001).

Conclusions: Pharyngocutaneous fistula is a common complication of total laryngectomy. Preoperative tracheostomy, postoperative hemoglobin, and surgical technique are important in determining the risk of fistula.
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http://dx.doi.org/10.1016/j.amjoto.2014.08.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385716PMC
August 2015

Activation of the NOTCH pathway in head and neck cancer.

Cancer Res 2014 Feb 18;74(4):1091-104. Epub 2013 Dec 18.

Authors' Affiliations: Departments of Otolaryngology-Head and Neck Surgery, Oncology and Health Science Informatics, Surgery, Oncology, and Pathology, Johns Hopkins Medical Institutions; Milton J. Dance Head and Neck Center, Greater Baltimore Medical Center, Baltimore, Maryland; and Asuragen Inc., Austin, Texas.

NOTCH1 mutations have been reported to occur in 10% to 15% of head and neck squamous cell carcinomas (HNSCC). To determine the significance of these mutations, we embarked upon a comprehensive study of NOTCH signaling in a cohort of 44 HNSCC tumors and 25 normal mucosal samples through a set of expression, copy number, methylation, and mutation analyses. Copy number increases were identified in NOTCH pathway genes, including the NOTCH ligand JAG1. Gene set analysis defined a differential expression of the NOTCH signaling pathway in HNSCC relative to normal tissues. Analysis of individual pathway-related genes revealed overexpression of ligands JAG1 and JAG2 and receptor NOTCH3. In 32% of the HNSCC examined, activation of the downstream NOTCH effectors HES1/HEY1 was documented. Notably, exomic sequencing identified 5 novel inactivating NOTCH1 mutations in 4 of the 37 tumors analyzed, with none of these tumors exhibiting HES1/HEY1 overexpression. Our results revealed a bimodal pattern of NOTCH pathway alterations in HNSCC, with a smaller subset exhibiting inactivating NOTCH1 receptor mutations but a larger subset exhibiting other NOTCH1 pathway alterations, including increases in expression or gene copy number of the receptor or ligands as well as downstream pathway activation. Our results imply that therapies that target the NOTCH pathway may be more widely suitable for HNSCC treatment than appreciated currently.
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http://dx.doi.org/10.1158/0008-5472.CAN-13-1259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3944644PMC
February 2014

Dengue fever: a primer for the otolaryngologist.

Ear Nose Throat J 2013 Jul;92(7):E5-9

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-9035, USA.

It has been estimated that more than 50 million cases of dengue occur worldwide each year, mostly in the tropics. In light of recent cases appearing in central and southern Florida, dengue has reemerged as a public health issue in the United States with respect to infection control and prevention. We review the course of dengue infection and its clinical presentation from the perspective of the practicing otolaryngologist, and we outline tactics for prevention and management.
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http://dx.doi.org/10.1177/014556131309200713DOI Listing
July 2013

Recurrence patterns and management of oral cavity premalignant lesions.

Oral Oncol 2013 Aug 18;49(8):814-7. Epub 2013 May 18.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287-0910, USA.

Objective: To gain an understanding of head and neck mucosal premalignant recurrence and progression based on histology, treatment modality, and risk factors.

Design: Retrospective chart review.

Setting: Academic medical center.

Patients: Patients who were followed or treated for oral cavity dysplasia/carcinoma in situ.

Main Outcomes Measures: Comparisons with clinical features, degree of dysplasia, anatomical location, rate of recurrences as well as malignant transformation and overall outcome were made.

Results: Of the 136 patients who were included in the study, 20% (n = 27) initially presented with mild dysplasia, 39% (n = 53) with moderate dysplasia, 21% (n = 29) with severe dysplasia, and 20% (n = 27) with carcinoma in situ. Wide local excision (HR 0.54, p = 0.05) was associated with reduced local recurrence in comparison to observation. In comparison to observation, both wide local excision (HR 0.43, p = 0.04) and CO(2)/NO Yag laser treatment (HR 0.14, p = 0.02) of dysplastic lesions significantly reduced progression to cancer. Management of mild dysplasia included observation (n = 13), excision (n = 10) and laser therapy (n = 3). Six of the 13 observed patients suffered a premalignancy recurrence, whereas only 4 of the 13 patients who underwent excision/laser treatment experienced a recurrence. Similarly, 5/13 observed patients eventually progressed to malignancy in comparison to only 2/13 patients who underwent initial excision/laser treatment.

Conclusion: Wide excision and/or ablation of head and neck mucosal premalignancy is more effective than observation in preventing recurrence of premalignancy and progression to malignancy. Mild dysplasia has a potentially high rate of recurrence and progression to malignancy when observed, and may be treated by wide excision or ablation.
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http://dx.doi.org/10.1016/j.oraloncology.2013.04.008DOI Listing
August 2013

Impact of pharyngeal closure technique on fistula after salvage laryngectomy.

JAMA Otolaryngol Head Neck Surg 2013 Nov;139(11):1156-62

Department of Otolaryngology-Head & Neck Surgery, Northwestern University, Chicago, Illinois.

Importance: No consensus exists as to the best technique, or techniques, to optimize wound healing, decrease pharyngocutaneous fistula formation, and shorten both hospital length of stay and time to initiation of oral intake after salvage laryngectomy. We sought to combine the recent experience of multiple high-volume institutions, with different reconstructive preferences, in the management of pharyngeal closure technique for post-radiation therapy salvage total laryngectomy in an effort to bring clarity to this clinical challenge.

Objective: To determine if the use of vascularized flaps in either an onlay or interposed fashion reduces the incidence or duration of pharyngocutaneous fistula after salvage laryngectomy compared with simple primary closure of the pharynx.

Design: Multi-institutional retrospective review of all patients undergoing total laryngectomy after having received definitive radiation therapy with or without chemotherapy between January 2005 and January 2012, conducted at 7 academic medical centers.

Setting: Academic, tertiary referral centers.

Patients: The study population comprised 359 patients from 8 institutions. All patients had a history of laryngeal irradiation and underwent laryngectomy between 2005 and 2012. They were grouped as primary closure, pectoralis myofascial onlay flap, or interposed free tissue. All patients had a minimum of 4 months follow-up.

Main Outcomes And Measures: Fistula incidence, severity, and predictors of fistula.

Results: Of the 359 patients, fistula occurred in 94 (27%). For patients with fistula, hospital stay increased from 8.9 to 12.1 days (P < .001) and oral diet initiation was delayed from 10.5 days to 29.9 days (P < .001). Patients were grouped according to closure technique: primary closure (n = 99), pectoralis onlay flap (n = 40), and interposed free tissue (n = 220). Incidence of fistula with primary closure was 34%. For the interposed free flap group, the fistula rate was lower at 25% (P = .07). Incidence of fistula was the lowest for the pectoralis onlay group at 15% (P = .02). Multivariate analysis confirmed a significantly lower fistula rate with either flap technique. For patients who developed fistula, mean duration of fistula was significantly prolonged with primary closure (14.0 weeks) compared with pectoralis flap (9.0 weeks) and free flap (6.5 weeks).

Conclusions And Relevance: Pharyngocutaneous fistula remains a significant problem following salvage laryngectomy. Use of nonirradiated, vascularized flaps reduced the incidence and duration of fistula and should be considered during salvage laryngectomy.
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http://dx.doi.org/10.1001/jamaoto.2013.2761DOI Listing
November 2013

Comparison of promoter hypermethylation pattern in salivary rinses collected with and without an exfoliating brush from patients with HNSCC.

PLoS One 2012 16;7(3):e33642. Epub 2012 Mar 16.

Department of Otolaryngology-Head and Neck Surgery, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America.

Background: Salivary rinses have been recently proposed as a valuable resource for the development of epigenetic biomarkers for detection and monitoring of head and neck squamous cell carcinoma (HNSCC). Both salivary rinses collected with and without an exfoliating brush from patients with HNSCC are used in detection of promoter hypermethylation, yet their correlation of promoter hypermethylation has not been evaluated. This study was to evaluate the concordance of promoter hypermethylation between salivary rinses collected with and without an exfoliating brush from patients with HNSCC. METHODOLGY: 57 paired salivary rinses collected with or without an exfoliating brush from identical HNSCC patients were evaluated for promoter hypermethylation status using Quantitative Methylation-Specific PCR. Target tumor suppressor gene promoter regions were selected based on our previous studies describing a panel for HNSCC screening and surveillance, including P16, CCNA1, DCC, TIMP3, MGMT, DAPK and MINT31.

Principal Findings: In salivary rinses collected with and without brush, frequent methylation was detected in P16 (8.8% vs. 5.2%), CCNA1 (26.3% vs. 22.8%), DCC (33.3% vs. 29.8%), TIMP3 (31.6% vs. 36.8%), MGMT (29.8% vs. 38.6%), DAPK (14.0% vs. 19.2%), and MINT31 (10.5% vs. 8.8%). Spearman's rank correlation coefficient showed a positive correlation between salivary rinses collected with and without brush for P16 (ρ = 0.79), CCNA1 (ρ = 0.61), DCC (ρ = 0.58), TIMP3 (ρ = 0.10), MGMT (ρ = 0.70), DAPK (ρ = 0.51) and MINT31 (ρ = 0.72) (P<0.01). The percent agreement of promoter methylation between salivary rinses with brush and without brush were 96.5% for P16, 82.5% for CCNA1, 78.9% for DCC, 59.7% for TIMP3, 84.2% for MGMT, 84.2% for DAPK, and 94.7% for MINT31.

Conclusions: Our study demonstrated strong correlations of gene promoter hypermethylation between salivary rinses collected with and without an exfoliating brush. Salivary rinse collection without using an exfoliating brush may offer a cost effective, rapid, non-invasive, and reliable means for development of epigenetic salivary rinse biomarkers.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033642PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306276PMC
August 2012

Laparoscopic hybrid NOTES liver resection for metastatic colorectal cancer.

Surg Laparosc Endosc Percutan Tech 2012 Feb;22(1):e5-7

Department of Surgery, University of Florida College of Medicine Jacksonville, Faculty Clinic, Jacksonville, FL 32209, USA.

Background: Abdominal wound extraction site continues to be a major source of morbidity after laparoscopic-assisted surgery.

Methods: A 59-year-old African American woman with a past history of T3N2M1 colon cancer, who underwent laparoscopic sigmoid colectomy and wedge liver resection (segment IV A) followed by adjuvant chemotherapy was our subject for this study. Twelve months later, she was found to have a positron emission tomography positive liver lesion of 6.5 cm at the left lateral liver segment. A combined laparoscopic-transvaginal approach was used. Four 5-mm trocars were used. The liver parenchyma was divided using the harmonic scalpel, whereas the left hepatic vein was transected using the laparoscopic transvaginal vascular stapler. The specimen was placed in an endobag and extracted transvaginally. The specimen size was 14×8×3.5 cm and that of the lesion was 6.5×5.7×4 cm. The patient was discharged on postoperative day 2.

Results: Operative time was 120 minutes and blood loss was minimal. The patient was discharged on postoperative day 2. No postoperative complications were found after 30 days.

Conclusions: Laparoscopic-assisted natural orifice transluminal endoscopic surgery results in quicker recovery, less postoperative pain, and potential wound-related complications. This technique is safe and effective with excellent aesthetic results. (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A54).
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http://dx.doi.org/10.1097/SLE.0b013e31823f7596DOI Listing
February 2012

Detection of TIMP3 promoter hypermethylation in salivary rinse as an independent predictor of local recurrence-free survival in head and neck cancer.

Clin Cancer Res 2012 Feb 6;18(4):1082-91. Epub 2012 Jan 6.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.

Purpose: To validate a panel of methylation-based salivary rinse biomarkers (P16, CCNA1, DCC, TIMP3, MGMT, DAPK, and MINT31) previously shown to be independently associated with poor overall survival and local recurrence in a larger, separate cohort of patients with head and neck squamous cell carcinoma (HNSCC).

Experimental Design: One hundred ninety-seven patients were included. All pretreatment saliva DNA samples were evaluated for the methylation status of the gene promoters by quantitative methylation-specific PCR. The main outcome measures were overall survival, local recurrence-free survival, and disease-free survival.

Results: In univariate analyses, the detection of hypermethylation of CCNA1, MGMT, and MINT31 was significantly associated with poor overall survival; the detection of hypermethylation of TIMP3 was significantly associated with local recurrence-free survival; and the detection of hypermethylation of MINT31 was significantly associated with poor disease-free survival. In multivariate analyses, detection of hypermethylation at any single marker was not predictive of overall survival in patients with HNSCC; detection of hypermethylation of TIMP3 in salivary rinse had an independent, significant association with local recurrence-free survival (HR = 2.51; 95% CI: 1.10-5.68); and none of the studied markers was significantly associated with disease-free survival.

Conclusion: The detection of promoter hypermethylation of the seven genes in salivary rinse as an independent prognostic indicator of overall survival in patients with HNSCC was not validated. Detection of promoter hypermethylation of TIMP3 in pretreatment salivary rinse is independently associated with local recurrence-free survival in patients with HNSCC and may be a valuable salivary rinse biomarker for HNSCC recurrence.
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http://dx.doi.org/10.1158/1078-0432.CCR-11-2392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3288549PMC
February 2012

Correlation of mucociliary clearance and symptomatology before and after adenoidectomy in children.

Int J Pediatr Otorhinolaryngol 2011 Oct 17;75(10):1318-21. Epub 2011 Aug 17.

University of Florida College of Medicine, USA.

Objective: The goal of this study is to better understand the role of adenoid hypertrophy and its impact on mucociliary clearance as it relates to the symptoms of chronic sinusitis in children. More specifically, the goal is to better understand which symptoms of chronic rhinosinusitis might be most likely to improve in children undergoing an adenoidectomy.

Methods: We conducted this study on 35 healthy children (>3 and <18 years of age), either male or female, who underwent adenotonsillectomy or adenoidectomy (with or without tympanostomy tube insertion). Eighteen patients completed pre- and postoperative surveys, with 10 also completing the Andersen's saccharine test (AST). The nasal mucociliary clearance will be evaluated with the AST, in which a saccharin particle (1.5mm diameter) is carefully placed on the floor of the nasal cavity approximately 1cm behind the anterior end of the inferior turbinate. The time taken by the subjects from placement of particle to the perception of the sweet taste will be taken as mucociliary clearance time (MCT). The length of the nasal cavity is measured intraoperatively as the distance between the upper medial incisor and the inferior edge of the soft palate. From these two values nasal mucociliary clearance velocity (MCV) (cm/min) can be calculated and assessed. This study took place at an academic institution.

Results: Symptomatic improvement was seen in all categories, as measured by the mean score improvement postoperatively. The greatest improvements were seen in nasal obstruction (mean=2.67 points ± .59) on the symptom survey, and emotional distress (mean=2.56 ± .47) on the SN5 survey. Quality of life improved by a mean=2.61 ± .49. Both MCT and MCV improved postoperatively (mean 3.64 min ± .84 and mean 1.96 cm/min ±.90, respectively).

Conclusions: We believe this study has the potential to provide otolaryngologists across the country with a benchmark to communicate the specific symptomatic benefits from adenoidectomy.
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http://dx.doi.org/10.1016/j.ijporl.2011.07.024DOI Listing
October 2011

"Redo" fundoplications: satisfactory symptomatic outcomes with higher cost of care.

J Surg Res 2007 Nov;143(1):183-8

Department of Surgery, University of South Florida, Tampa, Florida 33601, USA.

Introduction: With ever greater numbers of fundoplications being undertaken, inevitably there will be an increase in the number of failed fundoplications, which will be considered for operative revision. This study was undertaken to compare the hospital costs of and outcomes after "redo" fundoplications to those of "first time" fundoplications.

Methods: Patients undergoing anti-reflux surgery were prospectively followed. From 2000 to 2006, costs of and outcomes after 76 "redo" fundoplications were compared with 76 concurrent "first time" fundoplications. Prior to and after fundoplication, patients scored the frequency and severity of many symptoms, including dysphagia, chest pain, regurgitation, choking, and heartburn, using a Likert scale (0 = none/never, 10 = severe/always). The cost of care, including medical equipment, operating room expenses, and anesthesia was determined with standardization to 2006 cost and dollars. Data are presented as median (mean +/- standard deviation) where appropriate.

Results: Prior to "redo" fundoplications, patients reported significantly greater dysphagia frequency and severity scores and significantly greater chest pain severity. DeMeester scores for patients undergoing "redo" fundoplications versus "first time" fundoplications were similar (45 (62 +/- 55.6) versus 39 (44 +/- 27.7)). After fundoplication, dysphagia frequency and severity significantly improved for all patients. Length of stay was significantly longer for patients requiring "redo" fundoplications [3 d (6 +/- 8.5) versus 1 d (3 +/- 7.6)]. Hospital costs for patients undergoing "redo" fundoplications were significantly greater.

Conclusions: Patients requiring re-operative fundoplications report more frequent and severe symptoms, especially of dysphagia, when compared with patients undergoing "first-time" fundoplications. Laparoscopic "redo" fundoplications are technically challenging, more expensive, and more morbid (e.g., longer hospital stays). However, symptoms of reflux and dysphagia are ameliorated with "redo" fundoplications and application of "redo" fundoplication is warranted.
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http://dx.doi.org/10.1016/j.jss.2007.03.078DOI Listing
November 2007

Results after laparoscopic fundoplication: does age matter?

Am Surg 2006 Sep;72(9):778-83; discussion 783-4

Digestive Disorders Center, Department of Surgery, Tampa General Hospital and the University of South Florida, College of Medicine, Florida 33601, USA.

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward popu lation of older patients. One hundred eight patients more than 70 years of age (range, 70-90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18-59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores (P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved (P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores (P < 0.01) and lower reflux scores (P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.
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September 2006