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Background Sentinel lymph node biopsy (SLNB), an acceptable alternative to axillary lymph node dissection for staging patients with breast cancer, was introduced to clinical practice in the late 1990s. We assessed demographic, clinical, and facility-related factors associated with SLNB in women with early-stage breast cancer and evaluated trends in these factors over time. Methods Data on early-stage breast cancers (T1a, T1b, T1c, and T2N0) diagnosed between January 1, 1998, and December 31, 2005, were extracted from the National Cancer Database, a hospital-based registry. Patient demographics, tumor stage, type of lymph node surgery, type of breast cancer surgery, health insurance, treatment facility type, and area-level education and income variables were collected. Multivariable logistic regression analyses were performed to assess predictive factors associated with SLNB, temporal differences in factors associated with SLNB, and differences in rates of SLNB by facility type, race/ethnicity, and type of health insurance over time. Results The total analytic study population included 490899 women. The use of SLNB increased from 26.8% in 1998 to 65.5% in 2005. Factors associated with lower likelihood of SLNB over the study period included being older (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.78 to 0.92 for those aged 72 or older compared with those aged 51 or younger), being of racial/ethnic minority (OR = 0.76, 95% CI = 0.74 to 0.78 for African Americans compared with whites), having no health insurance (OR = 0.77, 95% CI = 0.73 to 0.80 for uninsured compared with having private insurance), having certain government insurance plans (for Medicaid, OR = 0.81, 95% CI = 0.78 to 0.84, and for Medicare at age Conclusions Although use of SLNB increased from 1998 to 2005, disparities persisted in receipt of SLNB that are based on nonclinical factors, including sociodemographic characteristics and insurance status.

The performance of hyperspectral imaging (HSI) for tumor detection is investigated in ex-vivo specimens from the thyroid (N = 200) and salivary glands (N = 16) from 82 patients. Tissues were imaged with HSI in broadband reflectance and autofluorescence modes. For comparison, the tissues were imaged with two fluorescent dyes. Additionally, HSI was used to synthesize three-band RGB multiplex images to represent the human-eye response and Gaussian RGBs, which are referred to as HSI-synthesized RGB images. Using histological ground truths, deep learning algorithms were developed for tumor detection. For the classification of thyroid tumors, HSI-synthesized RGB images achieved the best performance with an AUC score of 0.90. In salivary glands, HSI had the best performance with 0.92 AUC score. This study demonstrates that HSI could aid surgeons and pathologists in detecting tumors of the thyroid and salivary glands.

This paper by Drs. Bhayani, Holsinger, and Lai describes a new approach to an old problem. Advances in the management of head and neck cancer over the past few decades [...]

IMPORTANCE: The factors that contribute to gender discrepancies among attending head and neck surgeons have yet to be fully characterized. OBJECTIVE: To evaluate the association of gender difference with the perceived quality of life of head and neck oncological surgeons. DESIGN, SETTING, AND PARTICIPANTS: Following approval from the American Head and Neck Society (AHNS) review board, a web-based survey study of 37 questions, mainly assessing daily lifestyle and quality of life, was sent to the entire membership. MAIN OUTCOMES AND MEASURES: The main outcome assessed was perceived quality of life among female and male surgeons. RESULTS: A total of 261 members (13.0%) responded, 71 women (27.2%) and 190 men (72.8%). In all, 66 female (92.5%) and 152 male (80%) surgeons worked at an academic institution. A greater percentage of women were at the associate professor level than men (20/64 [31%] vs 37/152 [24%]; difference, 6.9%; 95% CI, −5.6% to 20.5%) and a greater percentage of men were at the professor level than women (72/152 [47%] vs 18/64 [28%]; difference, 19%; 95% CI, 4.9% to 31.6%). This discrepancy was evident in administrative roles as well, with 4 female (6.2%) vs 23 male (17.6%) department chairs (difference, 11.3%; 95% CI, 0.9%-19.6%). Of the 71 women, 18 (25%) were not in a long-term relationship or were divorced, as opposed to 6 (3.2%) men (difference, 22%; 95% CI, 12.8%-33.5%). Women had a mean (median) 1.18 (1) children, whereas men had 2.29 (2) children. Mean age that participating women had their first child was 35.1 years, whereas the man age for men was 31.9 years. Overall, 117 men (61.9%) and 45 women (67.2%) found their family time limited compared with other otolaryngological subspecialties. Despite these results, 101 men (53.4%) vs 37 women (55.2%) stated that they had a good work-life balance. Six women vs 8 men indicated they would choose a different subspecialty if they could. CONCLUSIONS AND RELEVANCE: Despite improvements in work hours and gender balance in residency programs, discrepancy in the number of female surgeons with senior academic rankings continues. However, female and male head and neck surgeons appear equally content with their subspecialty choice.

Head and neck malignancies comprise a heterogeneous group of malignancies that cause significant morbidity to those affected. These malignancies are associated with specific risk factors and exposures, some of which impact prognosis. The most common risk factors for developing head and neck cancers are tobacco and alcohol use. Marijuana and e-cigarettes, occupational exposures, and use of topical substances have also been linked to head and neck cancers. Human papilloma virus has been associated with oropharyngeal cancer. Such measures as oral hygiene, screening, smoking cessation, and vaccination are measures taken to decrease the incidence and morbidity of head and neck cancers.

Medullary thyroid carcinoma (MTC), an uncommon C cell thyroid malignancy, accounts for a disproportionate number of thyroid cancer deaths. To predict MTC clinical behavior, the recent international MTC grading system (IMTCGS) was published combining features from the Memorial Sloan Kettering Cancer Center and Royal North Shore Hospital grading systems that incorporates mitotic count, necrosis, and Ki67 proliferative index (Ki67PI). The IMTCGS appears promising, but independent validation data are limited. Here, we applied the IMTCGS to our institutional MTC cohort and assessed its ability to predict clinical outcomes. Our cohort comprised 87 MTCs (30 germline and 57 sporadic). Slides for each case were reviewed by 2 pathologists and histologic features recorded. Ki67 immunostaining was performed on all cases. Each MTC was graded with the IMTCGS based on tumor necrosis, Ki67PI, and mitotic count. Cox regression analysis was performed to assess the impact of various clinical and pathological data on disease outcomes, including overall survival (OS), disease-free survival, disease-specific survival (DSS), and distant metastasis-free survival. In our MTC cohort, 18.4% (n = 16/87) were IMTCGS high grade. IMTCGS grade was strongly prognostic for OS, disease-free survival, DSS, and distant metastasis-free survival on univariate analysis and multivariable analysis in both the entire MTC cohort and in the sporadic subset. Among the individual IMTCGS parameters, while all 3 were associated with poorer survival outcomes on univariate analysis, necrosis had the strongest association with all survival parameters on multivariable analysis, whereas Ki67PI or mitotic count was associated only with OS and DSS. This retrospective study independently demonstrates that the IMTCGS is valid for grading MTCs. Our findings support incorporating IMTCGS into routine pathology practice. IMTCGS grading may help clinicians to better predict the prognosis of MTC. Future studies may shed light on how MTC grading should impact treatment protocols.

Background/Aim:Beginning in 2011, the Food and Drug Administration (FDA) approved the use of multikinase inhibitors (MKIs) for medullary thyroid cancers (MTCs), and in 2013 MKIs were approved for metastatic differentiated thyroid cancers (DTCs). However, little is known about the use of chemotherapy in thyroid cancer patients. Thus, the goal of our study was to describe patterns of chemotherapy use, including MKIs, among DTC and MTC patients in the National Cancer Database (NCDB). Methods:Chemotherapy use, along with other treatment types (surgery and radiation), was assessed between 2004 and 2013. The primary predictor was the year of diagnosis (2004-2010 and 2011-2013), based on the FDA's approval of chemotherapy for MTC (2011). Baseline use of MKIs in DTCs in 2013 was also examined. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% CI of receipt of chemotherapy. Results:Overall, 199,654 patients were included in our analytic sample with 194,667 nonmetastatic DTCs, 1,633 metastatic DTCs, and 3,354 MTCs. Among MTCs, chemotherapy use significantly increased from 3.1% in 2004-2010 to 5.0% in 2011-2013 (p = 0.018) in unadjusted and adjusted (OR = 1.54, 95% CI: 1.00, 2.36) analyses. In metastatic DTCs, 4.9% of patients received chemotherapy in 2013, which was not significantly higher than in previous years (p = 0.755). Conclusions:Overall, chemotherapy use among MTCs increased marginally following the FDA's approval of MKIs in 2011, although their use remains very low. MKIs were infrequently used in metastatic DTCs in 2013. Future studies examining patterns of chemotherapy in thyroid cancer patients are warranted.

IMPORTANCE: Medullary thyroid cancer (MTC) is a relatively rare neoplasm of the thyroid but accounts for 14% of thyroid cancer–related deaths. Female sex, young age, and stage at presentation have been found to predict survival and treatment. However, patterns of survival and treatment by socioeconomic status and race/ethnicity have not been fully described. OBJECTIVE: To determine whether socioeconomic status and race/ethnicity are associated with survival and treatment in patients with MTC. DESIGN, SETTING, AND PARTICIPANTS: Data for 1647 patients with MTC from January 1, 1998, to December 31, 2011, in the Surveillance, Epidemiology, and End Results (SEER) Program registry were examined. Data analysis was conducted from June 1, 2013, to July 31, 2014. MAIN OUTCOMES AND MEASURES: Differences in receipt of thyroidectomy and lymph node examination by race/ethnicity were examined using logistic regression models. Overall and disease-specific survival were examined by race/ethnicity using Kaplan-Meier survival curves and adjusted Cox proportional hazards regression models. RESULTS: Of the 1647 patients with MTC were 1192 white (72.4%), 139 black (8.4%), 222 Hispanic (13.5%), and 94 other races/ethnicities (5.7%). Of these, 1539 (93.4%) underwent surgical treatment. There were no differences in receipt of thyroidectomy by race/ethnicity; however, black patients (adjusted odds ratio, 0.61; 95% CI, 0.39-0.93) and female patients (adjusted odds ratio, 0.76; 95% CI, 0.59-0.99) were less likely to undergo lymph node examination compared with non-Hispanic white and male patients. Black patients had lower overall (adjusted hazard ratio, 2.40; 95% CI, 1.45-3.98) and disease-specific survival (adjusted hazard ratio, 2.9; 95% CI, 1.64-5.14) compared with non-Hispanic white patients. CONCLUSIONS AND REVELANCE: In this population-based study of patients with MTC, black patients were less likely to have lymph node examination following surgery. Furthermore, Hispanic and black patients had poorer overall and disease-specific survival compared with non-Hispanic white patients after accounting for clinical factors. Racial/ethnic disparities exist in the type of treatment as well as outcomes in patients with MTC.

IMPORTANCE: Previous studies of prognostic factors of carcinoma of the minor salivary gland (MSG) have been limited to single-institution studies and small case series. Thus, limited data are available to guide the head and neck oncologist in counseling patients on the prognosis and management of these malignant neoplasms. OBJECTIVE: To examine 5- and 10-year cause-specific survival (CSS) rates of MSG carcinomas across all histologic subtypes and head and neck tumor subsites. DESIGN, SETTING, AND PATIENTS: Retrospective, population-based study using National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) data from January 1, 1988, through December 31, 2009. The study included 5334 patients diagnosed as having MSG carcinoma and registered in the SEER database. Patients without follow-up, diagnostic confirmation, and/or race designation were excluded from the analysis (131 [2.4%]). Final follow-up was completed on December 31, 2009, and data were analyzed from August 5, 2013, to July 1, 2014. MAIN OUTCOMES AND MEASURES: Five- and 10-year CSS rates for US patients with MSG carcinoma. Cox proportional hazard models were used to estimate adjusted hazard ratios (HRs) and 95% CIs. RESULTS: Among the 5334 patients with MSG carcinoma included, the most common histologic subtypes included mucoepidermoid carcinoma (1568 [29.4%]), adenoid cystic carcinoma (1228 [23.0%]), and adenocarcinoma (1313 [24.6%]). The most frequent sites of primary tumor were the oral cavity (3132 [58.7%]) and pharynx (1130 [21.2%]). Five-year CSS rate was significantly worse for MSG malignant neoplasms located in the larynx (HR, 2.42; 95% CI, 1.67-3.50) and nasal cavity and/or paranasal sinus (HR, 1.73; 95% CI, 1.29-2.32). Being older than 75 years was associated with a significantly worse 5-year CSS rate (HR, 2.88; 95% CI, 2.05-4.06). Compared with no surgery, local tumor destruction (HR, 0.44; 95% CI, 0.30-0.64), partial surgery (HR, 0.33; 95% CI, 0.23-0.47), and total surgery (HR, 0.55; 95% CI, 0.41-0.74) were each found to be a significant positive prognostic factor. No differences were observed in the 5-year hazard of death for race/ethnicity, sex, diagnosis year, or socioeconomic status, and 10-year adjusted HRs were similar to the 5-year patterns. CONCLUSIONS AND RELEVANCE: This study, to date, represents the largest US survival analysis of carcinoma of the MSG. Prognosis is associated with histologic subtype, tumor subsite, age at diagnosis, grade, and surgical therapy.

IMPORTANCE: Cost containment is at the forefront of responsible health care delivery. One way to decrease costs is to decrease hospital length of stay (LOS). Data are lacking on factors contributing to LOS in patients with head and neck cancer (HNC) undergoing fibular free-tissue reconstruction (FFTR) of head and neck defects. OBJECTIVE: To identify factors contributing to increased LOS following FFTR of head and neck defects in patients with HNC using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) methodology. DESIGN: Retrospective medical record review, with reference to the ACS NSQIP form, of 30 consecutive patients with HNC undergoing FFTR of head and neck defects in a single tertiary academic institution from July 2013 through June 2014. Data were collected on demographic and tumor characteristics, preoperative risk factors, operative variables, and postoperative adverse events. MAIN OUTCOMES AND MEASURES: Factors associated with increased hospital LOS. RESULTS: Median LOS was 10 days (range, 8-31 days), and patients were divided into 2 groups (LOS, ≤10 days [n = 16]; and LOS, >10 days [n = 14]). There were no significant differences in demographics, tumor characteristics, or preoperative medical comorbidities between the 2 groups. Univariate analysis demonstrated that operative time, ventilator dependence, wound event, and altered mental status were associated with longer LOS. Multivariate analysis revealed significant association with LOS greater than 10 days for operative time of longer than 11 hours (odds ratio [OR], 7.26; 95% CI, 1.12-47.29; P = .04) and ventilator dependence for more than 48 hours postoperatively (OR, 12.05; 95% CI, 1.06-137.43; P = .045). CONCLUSIONS AND RELEVANCE: Evaluated by the ACS NSQIP criteria, FFTR of head and neck defects in patients with HNC was associated with LOS longer than 10 days for procedures lasting longer than 11 hours and for patients who are ventilator dependent for more than 48 hours.

OBJECTIVE To investigate whether patients treated with laryngectomy had less comorbidity than those treated with chemoradiation, which could help explain the improved survival for the laryngectomy cohorts in recent studies. DESIGN Observational cross-sectional study. PATIENTS Patients receiving diagnoses of primary invasive advanced squamous cell carcinoma of the larynx between 2003 and 2008 were selected from the National Cancer Database, which collects information from more than 1400 facilities accredited by the American College of Surgeons' Commission on Cancer. Patient-level independent variables included age at diagnosis, sex, diagnosis year, race/ethnicity, primary payer status, and zip code–level education. MAIN OUTCOME MEASURES Primary treatment information. The association between treatment and patient clinical, sociodemographic, and facility-level and zip code–level socioeconomic status variables were analyzed using univariate statistics and multivariate models. Charlson Deyo Comorbidity and The Washington University Head and Neck Comorbidity Index scores were calculated from the hospital face sheet. RESULTS The study demonstrated that receipt of treatment (chemoradiation vs total laryngectomy) was significantly associated with comorbidity. Treatment was not significantly associated with insurance status, race/ethnicity, or age. Patients with comorbidity were less likely to receive chemoradiation than subtotal or total laryngectomy, with a risk ratio (RR) of 0.84 (95% CI, 0.81-0.87) for patients with 1 or more comorbidities compared with those without any comorbidity, after controlling for factors such as tumor stage, age, race/ethnicity, insurance, and socioeconomic status. Patients were also less likely to receive chemoradiation than total laryngectomy if they had stage IV disease (RR, 0.81; 95% CI, 0.79-0.83) and if they had been diagnosed at a teaching or research institution (RR, 0.80; 95% CI, 0.77-0.84). Patients were more likely to receive chemoradiation if they were diagnosed after 2003 (RR, 1.37; 95% CI, 1.30-1.45) or if they lived in a zip code with a high percentage of high school graduates (RR, 1.1; 95% CI, 1.05-1.15). CONCLUSIONS This is the first study, to our knowledge, that demonstrates that patients with advanced laryngeal cancer with 1 or more comorbidities are more likely to receive surgery than chemoradiation compared with patients without any comorbidity, independent of numerous clinical and nonclinical variables among a large national cohort. A limitation of this study is the use of comorbidity data from the National Cancer Database, which gathers its information from hospital discharge face sheets. We recognize that the National Cancer Database may be an imperfect system for the collection of comorbidity data and encourage discussion on different methods to improve the system, including incorporating comorbidity data from the Surveillance, Epidemiology, and End Results Medicare Database and medical chart–based comorbidity data collection by cancer registrars.

OBJECTIVE To describe trends in mortality rates for patients with oral cavity and pharynx cancer by educational attainment, race/ethnicity, sex, and association with human papillomavirus infection. DESIGN Study of age-standardized mortality rates for patients with oral cavity and pharynx cancer by level of education using National Center for Health Statistics data. SETTING Twenty-six states. PATIENTS White and black men and women aged 25 to 64 years. MAIN OUTCOME MEASURE Age-standardized mortality rates for 2005 to 2007 and trends for 1993 to 2007. RESULTS From 1993 to 2007, overall mortality rates for patients with oral cavity and pharynx cancer decreased among black and white men and women; however, rates among white men have stabilized since 1999. The largest decreases in mortality rates were among black men and women with 12 years of education (−4.95% and −3.72%, respectively). Mortality rates for patients with oral cavity and pharynx cancers decreased significantly among men and women with more than 12 years of education, regardless of race/ethnicity (except for black women), whereas rates increased among white men with less than 12 years of education. Mortality trends vary substantially for human papillomavirus–related and human papillomavirus–unrelated sites. CONCLUSIONS We observed decreasing mortality rates for patients with oral cavity and pharyngeal cancer among whites and blacks; however, decreases were greatest among those with at least 12 years of education. This difference in mortality trends may reflect the changing prevalence of smoking and sexual behaviors among populations of different educational attainment.

OBJECTIVE To describe trends and 4-year survival rate of surgical and nonsurgical treatment for laryngeal cancer. DESIGN Observational cross-sectional study. PATIENTS A total of 131 694 cases of laryngeal cancer diagnosed from 1985 to 2007 identified from the National Cancer Database. MAIN OUTCOME MEASURES Primary treatment information, including radiation therapy (RT), chemoradiation (CRT), and curative intent surgery, were identified. The association between treatment and the patient's clinical and nonclinical variables was analyzed using univariate and multivariate statistics. The 4-year survival rate was generated through Kaplan-Meier estimates, and multivariate Cox proportional hazard models were used to generate hazard ratios. RESULTS Among patients with early-stage cancer, the proportion receiving primary surgery increased (from 20% in 1985 to 33% in 2007), whereas the use of RT decreased from 64% to 52%. Patients with early-stage cancer who resided in areas with higher socioeconomic status (SES) zip codes, had private insurance, who were not African American, and who were treated at academic facilities were more likely to receive surgery. The 4-year survival rate for patients with early-stage laryngeal cancer treated with surgery was higher than the rate for those treated with RT (79% vs 71%). Among patients with advanced-stage cancer, the use of CRT increased from less than 7% to 45%, whereas the use of total laryngectomy decreased from 42% to 32%. The use of CRT was more common among patients who resided in areas with higher SES zip codes, had private insurance, and who were younger. The 4-year survival rates for patients with advanced laryngeal cancer treated with total laryngectomy, CRT, and RT were 51%, 48%, and 38%, respectively. Factors associated with an increased risk of death from advanced laryngeal cancer included receiving CRT and race/ethnicity. CONCLUSIONS Among patients with early-stage laryngeal cancer, we observed an increasing proportion of primary surgical therapy during this study period. Among patients with advanced-stage cancer, we observed an increasing proportion of CRT. Not only were clinical factors associated with type of treatment, but select sociodemographic elements were also associated with treatment. Further investigation as to the decision-making process of patients with different sociodemographic backgrounds will assist in mitigating the differences in survival for this group of patients.

Objective:The aim of this study is to describe patterns of care of advanced oropharyngeal cancer during 1985 to 2001.

During cardiac c‐looping, the heart transforms from a straight tube into a c‐shaped tube, presenting the first evidence of left–right asymmetry in the embryo. C‐looping consists of two primary deformation components: ventral bending and dextral rotation. This study examines the role of actin polymerization in bending of the heart tube. Exposure of stage 9–11 chick embryos to low concentrations of the actin polymerization inhibitors cytochalasin D (5 nM–2.0 μM) and latrunculin A (LA; 25 nM–2.0 μM) suppressed looping in a stage‐ and concentration‐dependent manner in both whole embryos and isolated hearts. Local exposure of either the dorsal or ventral sides of isolated hearts to LA also inhibited looping, but less than global exposure, indicating that both sides contribute to the bending mechanism. Taken together, these data suggest that ongoing actin polymerization is required for the bending component of cardiac c‐looping, and we speculate that polymerization‐driven myocardial cell shape changes cause this deformation. Developmental Dynamics 233:1272–1286, 2005. © 2005 Wiley‐Liss, Inc.

Health status instruments are questionnaires that are utilized to assess changes in health status of individuals. These surveys are increasingly of importance as health care providers are challenged to justify treatment approach and rationale. Objective criteria (e.g. CT scan of the sinuses) can be used to determine whether there is clinical evidence of disease. However, the impact of the disease on the individual’s life is not included in such a clinical assessment. The use of validated and reliable health instruments is directed at measuring this impact in a reproducible and valid fashion. In patient-centered research, ‘experimental’ conditions are constantly changing because we are dealing with human beings with values, feelings, and perspectives. It is especially important to use valid measurement tools when assessing these impacts. This article outlines the principles of the development and validation of health status instruments and offers examples of such instruments from the otolaryngology literature.

Objective:To evaluate the cost‐effectiveness of several diagnostic tests used in the evaluation of vertigo.

The outer hair cell is thought to enhance the sensitivity of mammalian hearing. Its lateral wall consists of 3 concentric layers: an outermost plasma membrane, a cortical lattice, and an innermost collection of flattened membranes called the subsurface cisternae. The cytoplasm requires positive pressure for full expression of the outer hair cell's electromotility. Using micropipette aspiration, we investigated the mechanics of the guinea pig's outer hair cell lateral wall at room temperature (22°C) and at the guinea pig's body temperature (39°C). Although there was a 10% decrease in stiffness parameter with an increase from room to body temperature, the difference was not statistically significant; values ranged from 0.45 to 0.65 dyne/cm. With sufficient negative pressure, the cytoplasmic membrane is separated from the rest of the outer hair cell's lateral wall, a process that leads to vesiculation of the plasma membrane. Vesiculation occurs at a lower pressure than at body temperature. Our results demonstrate that the stiffness parameter of the outer hair cell lateral wall at body temperature is similar to that at room temperature. However, the plasma membrane's attachment to the cortical lattice is greatly altered by temperature. The decrease in strength of membrane attachment at body temperature may result from a change in membrane fluidity, making it more easy for membrane attachment sites to break free and permit vesiculation. Whether the tethering of the plasma membrane to the cortical lattice is lost under clinically pathologic conditions deserves future study.

The cause of hearing loss in children is often difficult to identify. We evaluated a cohort of 114 children (47 boys, 67 girls) referred with newly diagnosed hearing loss (non–otitis media) to identify factors predictive of etiology and type of hearing loss. Clinical (history and physical examination), laboratory, and radiographic data were collected. One hundred children (87.7%) had sensorineural hearing loss, and 14 (12.3%) had conductive or mixed hearing loss. The cause of hearing loss was identified in 54 children (48%). Patients with isolated aural atresia (n= 7) or with a known diagnosis of congenital cytomegalovirus infection (n= 21) were excluded from further data analysis. We conducted statistical analysis to identify factors predictive of the cause and type of hearing loss. Clinical factors that aided in identifying a cause included abnormal physical examination findings (p= 0.001) and craniofacial anomalies (p= 0.006). Computed tomography of the temporal bones was the only diagnostic test predictive of cause (p< 0.001). Factors predictive of the type of hearing loss detected (sensorineural vs. conductive or mixed) were abnormal physical examination findings (p= 0.01) and craniofacial anomalies (p= 0.004). An exhaustive laboratory or radiographic workup did not prove beneficial in identifying the etiology of hearing loss in our series.

We reviewed 78 consecutive cases of penetrating facial injuries treated at Ben Taub General Hospital in Houston, Texas, between 1992 and 1994, and we analyzed injury patterns on the basis of (1) the mechanism of injury, and (2) the entry zone of the wounds. We found that gunshot wounds were more likely to require emergent airway establishment than shotgun wounds or stab wounds (p= 0.03). We noted a higher prevalence of globe injury among shotgun wounds than among gunshot wounds (p= 0.02). Nine (12%) patients had intracranial penetration of a bullet or shotgun pellet. Patients with gunshot wounds required open reduction and internal fixation of facial bone fractures more frequently than patients with shotgun wounds (p= 0.01). Thirty patients underwent arteriograms, and 10 demonstrated positive findings. Although there were only 3 deaths in our series, 29 (37%) patients overall had some complication caused by their penetrating facial trauma, including blindness in 12 patients. There was no significant difference in the prevalence of complications between gunshot, shotgun, and stab wounds (p= 0.18). With these injury patterns in mind, we describe an algorithm for evaluation and management of penetrating injuries of the face.

We performed a prospective study of 59 consecutive patients with facial trauma who were treated at an urban public hospital. We obtained demographic and clinical data before treatment, then recorded compliance with clinic follow-up care. As expected, young, minority male patients, victims of assault, and blunt mechanisms of injury predominated in our series, and midface fractures and soft tissue injuries were most commonly seen. Thirty-one (52%) patients were admitted, and 28 (48%) were treated as outpatients. Although 66% of patients kept their initial follow-up appointment, only 46% of patients were seen to completion of the follow-up period. We used univariate and multivariate analyses to identify factors predictive of poor compliance with follow-up care. Factors predictive of poor compliance with the initial follow-up appointment identified in the multivariate analysis were orbital injury site (p< 0.001), Caucasian race (p= 0.007), and not having a telephone at home (p= 0.043). Factors predictive of poor compliance with completion of follow-up were failure to keep initial appointment (p< 0.001), and treatment with observation, suture only, or open reduction internal fixation only (p= 0.018). Age, marital status, employment status, education level, and hospital admission of the patient were not predictive of compliance with follow-up care. Because compliance with follow-up care may be poor, patients with facial trauma should be managed aggressively initially. In particular, patients with orbital fractures, and those treated with watchful waiting only may have poorer long-term compliance with follow-up care. (Otolaryngol Head Neck Surg 1997;117:72–5.)

OBJECTIVES: To evaluate the prevalence of otolaryngologic disease in children born to mothers infected with human immunodeficiency virus (HIV) and to assess the correlation between HIV disease severity and the incidence density of recurrent otitis media (OM) and sinusitis based on the revised 1994 Centers for Disease Control and Prevention (CDC) clinical-severity index. DESIGN: Case series. SETTING: Academic, tertiary care children's hospital. PATIENTS: One hundred forty-five children (73 boys, 72 girls) with vertically acquired HIV infection and 153 (77 boys, 76 girls) children who had maternal exposure to HIV but later were found not to be infected ("seroreverters"), followed up on a regular basis since birth. MAIN OUTCOME MEASURES: Prevalence of recurrent OM (3 episodes in 6 months or 4 episodes in 12 months), sinusitis, parotitis, and lymphadenopathy; incidence density of recurrent OM and sinusitis based on the 1994 CDC clinical-severity index. RESULTS: Sixty-four HIV-infected children (44%) and 13 seroreverters (8.5%) had recurrent OM (P&lt;.001); 29 HIV-infected children (20%) and 1 seroreverter (0.6%) had sinusitis (P&lt;.001). Eight HIV-infected patients developed tympanic membrane perforations and 25 HIV-infected children required otologic surgery. Three HIV-infected patients had parotitis. The incidence density of recurrent OM increased as HIV clinical (P=.001) and immunologic (P=.03) status worsened. In contrast, the incidence density of sinusitis did not significantly correlate with increased HIV disease severity. CONCLUSION: The prevalence of recurrent OM and sinusitis is significantly greater in HIV-infected children than in seroreverters. The incidence density of recurrent OM also significantly correlates with disease progression in HIV-infected children as measured by the 1994 CDC clinical-severity index.Arch Otolaryngol Head Neck Surg. 1996;122:1360-1363