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Aim Many vascular patients present acutely, relying on emergency theatre availability when surgical intervention is required. The prioritisation of the CEPOD operating list is a challenge, and the additional pressures of the COVID-19 pandemic have necessitated changes to established practice. The purpose of this audit was to review the effects of the pandemic on the CEPOD waiting times for vascular patients at the main centre for the South West Wales Vascular Network. Method The CEPOD waiting times for vascular patients during the initial wave of the COVID-19 pandemic were compared with the same period the previous year. Data was analysed according to booking category and procedure type. Results 98 emergency vascular procedures were performed during the initial wave of the COVID pandemic, compared to 133 in 2019. In 2019, amputations (major and minor) accounted for 47% of cases, which rose to 53% during the pandemic. Median waiting times for category 1 and 2a operations were significantly shorter in 2020, whilst category 3 waiting times rose. There was no significant difference overall in the proportion of patients operated on within the target timescale, regardless of CEPOD booking category. Conclusions Managing the impact of COVID-19 required change to established practice. Although fewer procedures were performed, significant logistical challenges were faced. By adjusting the organisation of CEPOD, the most urgent vascular cases were performed quicker during this time. It is important to identify and promote the positive organisational changes that have arisen as a result of COVID-19, and to continue to review procedures as the pandemic progresses.

Chronic hepatitis C is associated with health-related quality of life and cognitive impairments, even in mild disease. Recent evidence demonstrating hepatitis C virus (HCV) neurotropism has strengthened a neuropathophysiological hypothesis. However, sample heterogeneity confounds study outcomes. A uniquely homogeneous cohort of Irish women, following an iatrogenic HCV outbreak, offers a rare opportunity to control for HCV chronicity and the virus' purported impact on quality of life and cognition. A multi site, three-group, cross-sectional design was employed. Noncirrhotic, iatrogenically infected women, developing either acute or chronic infection, were recruited from prospective tertiary-care liver clinics and the community. Well-matched healthy controls were also recruited. All participants completed a psychosocial survey and were invited to undergo a comprehensive neuropsychological test battery. Significantly distressed psychosocial symptom profiles were observed in those with an iatrogenic HCV exposure history, which was independent of viral chronicity. Chronic and cleared HCV cohorts were not differentiated from each other. Two distinct subgroups, demarcated along 'impaired' vs 'nonimpaired' quality-of-life reports, were clearly identified and logistic regression analysis identified depressed mood and cognitive fatigue, rather than viral status, as statistically significant predictors of group membership. Compared with matched controls, significant cognitive impairments were not observed in either HCV cohort. Our findings provide strong evidence of nonviral factors accounting for quality of life impairment in chronic HCV and they also appear to question existing reports of cognitive dysfunction in mild disease. Depressed mood and cognitive fatigue appear to be critical psychosocial mediators of reduced quality-of-life and we hypothesize that metabolite abnormalities reported in HCV samples may also be confounded by these factors, given the associated literature.

Objective: To compare growth of infants fed goat milk infant formula (GMF) or cow milk infant formula (CMF) and to compare tolerability and safety of the two formulas. Methods: The study was conducted in Auckland, New Zealand. This was a double-blind randomized controlled trial. Newborn term infants were randomized within 72 h of birth to GMF or CMF. Milk formula powder in single serve sachets were reconstituted and fed to infants from trial commencement until age 168 days. No other formula given from randomization until age 168 days. Infant weight, length and head circumference were measured at birth and age 14, 28, 56, 84, 112, 140 and 168 days. Bowel motion frequency and consistency, sleeping and crying patterns and adverse events were also measured. Results: Seventy-two infants were randomized, 36 each to GMF or CMF, with 62 infants completing the intervention. At enrolment the average weight of infants in the GMF group (mean ± SD) was 3.33 ± 0.43 kg and in the CMF group 3.43 ± 0.47 kg; and at study completion 8.07 ± 0.90 kg (GMF) and 7.87 ± 0.99 kg (CMF). The difference in average weight gain over the study period for the GMF group versus the CMF group was not significant (+309 g; 95% CI = −49 to +668, P = 0.09). Median daily bowel motion frequency was greater in the GMF group than the CMF group (2.4 vs 1.7, P = 0.01). There were no group differences in bowel motion consistency, duration of crying, ease of settling, or frequency of adverse events. Conclusion: Growth of infants fed GMF is not different to that of infants-fed CMF.

As temporal bone imaging techniques continue to improve, it is likely that we will see an increase in the detection of pneumolabyrinth. Several mechanisms have been proposed to explain how air enters the labyrinth. A small number of authors has reported an association between pneumolabyrinth and temporal bone fractures, perilymphatic fistulae, and displaced stapes prostheses. In this article, we describe a new case of pneumolabyrinth that was seen as a late complication of stapes surgery, and we summarize what is known about this rare condition.

Vagal paraganglioma is a rare tumor of neural crest origin. Although the literature is in agreement with regard to epidemiology, diagnosis, and tumor biology, there is some controversy over treatment modalities for these patients. We performed a nonrandomized retrospective study in a large single-institution series of patients (n = 19) in whom vagal paraganglioma was diagnosed. General statistics included age, male/female ratio, tumor size, and duration of follow-up. Other variables such as signs and symptoms at presentation, family history, multicentricity, metastatic disease, and secretion of catecholamines were included. CT scan, MRI, and angiography were used in combination for diagnostic purposes as well as for treatment planning. Preoperative embolization was performed in 5 of the more recently treated patients. Current issues regarding the use of preoperative embolization and choice of surgical approach were analyzed. In this article the possibility and sequela of vagus nerve-sparing procedures will be presented. Operative complications and postoperative morbidity related to cranial neuropathies will be discussed. The rationale for performing adjunct procedures, including cricopharyngeal myotomy and vocal fold medialization, to facilitate the rehabilitation of patients with postoperative cranial nerve deficits will be given. Our findings and recommendations will be compared with currently accepted treatment protocols in conjunction with a review of the literature.

We present only the 12th reported case of a laryngeal leiomyosarcoma. This tumor was diagnosed with the aid of the newer immunohistochemical stains on archival paraffin-embedded tissue. The diagnosis and management of these tumors is based largely on the patterns seen in the small number of earlier reported cases of head and neck leiomyosarcomas and laryngeal sarcomas.

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren ‘s-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Olfactory neuroblastoma is a rare malignancy of the olfactory mucosa that may be derived from the olfactory epithelium. To characterize this tumor, we cultured olfactory neuroblastoma cells in the presence or absence of growth factors (transforming growth factor alpha and basic fibroblast growth factor) known to affect olfactory tissue and assessed their responsiveness to known odorants by measuring changes in intracellular calcium. Untreated cells did not respond to odorants. Basic fibroblast growth factor treatment had cytotoxic effects, and treated cells did not respond to odorants. Transforming growth factor alpha treatment resulted in the induction of odor responsiveness in these cells. Cells responded to odorants at 100 nM to 100 microM concentrations and responded with both increases and decreases in intracellular calcium. Increases in intracellular calcium were mediated by a calcium influx and were reversibly blocked by compounds known to inhibit second messenger pathways in olfactory receptor neurons. The calcium responses of the olfactory neuroblastoma cells were thus specific to the odorants and similar to those found in olfactory receptor neurons. The results support the notion that olfactory neuroblastoma cells may be of olfactory origin and thus they can be used as a model cell line to study human olfaction.

Piroxicam like other Non-Steroidal Anti-Inflammatory drugs can be used to provide postoperative analgesia. With a half-life of 50 hr given preoperatively its’ analgesic effect should continue postoperatively. This study compared the effects of 20 mg piroxicam given at different times in the perioperative period on postoperative analgesic requirement. Following ethical committee approval and written informed consent, 60 ASA I and II patients presenting for inpatient gynaecological laparoscopic surgery were given either 20 mg piroxicam or a placebo po two hours preoperatively, immediately before induction of anaesthesia or one hour postoperatively in a randomised double bind manner. Postoperative Visual Analogue Pain Scores were lower on admission to the recovery ward in patients given piroxicam preoperatively (Group 1), than in the other two treatment groups (groups 2 and 3). Pain scores were 2.72 vs 4.25 vs 6.67 respectively (P < 0.001). Pain scores did not differ at any other times. Time to first analgesic request was greater in the group 1 than in the other two treatment groups; 141 (61) min vs 115 (147) in Group 2 and 30 (36) min in Group 3. Nine patients in Group 1 requested further analgesia compared with 15 in Group 2 and 16 in Group 3. There were no piroxicam-induced side-effects. Piroxicam given two hours preoperatively reduced pain scores, time to first analgesia and postoperative analgesic requirements compared with administration prior to induction or one hour postoperatively.

Patients with Kallmann syndrome (KS) exhibit hypogonadotropic hypoganadism and anosmia [Kallmann et al., Am. J. Mental Def., 48 (1944) 203–236] secondary to failure of gonadotropin-releasing hormone (GnRH)-producing neurons to migrate from the olfactory placode to the brain, and to agenesis of the olfactory bulbs. It has been hypothesized that olfactory neurons (ON) from individuals with KS are immature partly on the basis of studies in animals showing that lack of synaptic connection of ON with the olfactory bulb results in expression of immature ON [Schwob et al., J. Neurosci., 12 (1979) 880–883]. To test this assumption, we obtained olfactory tissue samples from two males diagnosed with KS on the basis of medical history and MRI studies. Both patients were anosmic. The functioning of cells isolated from biopsies taken from the upper middle turbinate and septum was studied by measuring changes in intracellular Ca2+ concentration ([Cai]) using dual excitation fluorescence microscopy. Biopsies from both patients yielded cells that morphologically appeared to be ON. Seven of 16 cells that morphologically resembled ON responded with a change in [Cai] upon stimulation with an odorant mixture. These studies show that at least some ON in KS individuals are functionally mature and suggest that complete development of the olfactory bulbs is not required for differentiation of mature human ON.

Giant cholesterol cyst (GCC) of the petrous apex is a rare clinical entity. This benign cystic lesion can cause neurologic deficits and vascular compromise by persistent growth and progressive bone destruction. Magnetic resonance imaging studies of GCC show the lesions to be hyperintense on T1-weighted sequences with progressively lower signal intensities on the first and second echoes of T2-weighted sequences. These findings are relatively specific for GCC, permitting a narrow differential diagnosis. The goal of surgery is to provide adequate drainage with the creation of a permanent fistula. The classic approaches to these lesions are the posterior fossa craniotomy and the middle fossa extradural craniotomy. The translabyrinthine approach provides wide exposure at the expense of cochlear and vestibular function. The transsphenoidal approach provides adequate drainage with hearing preservation and no craniotomy. The endoscopic, endonasal transsphenoidal approach to a 2.5 cm GCC of the petrous apex accomplished complete drainage with the creation of a fistula. Advances in endoscopic technique and instrumentation facilitated the addition of the approach to the surgeon's armamentarium. In selected cases, this approach provides adequate surgical exposure with minimal morbidity.

Dural sinus thrombosis is a rare, potentially fatal complication of a radical neck dissection. The prognosis can vary from complete recovery to rapid death. Magnetic resonance venography provides an effective, noninvasive diagnosis. The goals of therapy are to decrease intracranial pressure and to lyse the thrombus. Systemic anticoagulation and systemic thrombolytics are controversial therapies. The direct intrasinus infusion of thrombolytic agents is under investigation.

The association between nasal allergy and loss or diminution of smell is frequently alluded to in the literature; however, neither the true prevalence of hyposmia in individuals with allergic rhinitis nor its bases have been established.We assessed olfactory threshold for phenylethyl alcohol in 91 patients with symptoms of allergic rhinitis and 80 nonatopic control subjects. To determine the degree to which nasal congestion contributes to hyposmia in allergic rhinitis, total nasal resistance was measured in 64 of the patients and 72 of the control subjects.Olfactory thresholds were significantly higher in allergic patients than in control subjects (p0.001), with 23.1% of the patients demonstrating a clinically significant smell loss (defined as threshold at or above the 2.5th percentile of control values). Although nasal resistance was significantly higher among patients than among controls (p0.001), it was not related to olfactory threshold in either group. Clinical or radiographic evidence of sinusitis or nasal polyps or both in allergy patients was found to be significantly associated with hyposmia (p0.006).The observed prevalence of hyposmia among patients with allergic rhinitis suggests that this is a major etiologic factor contributing to smell disorders. Sinusitis or nasal polyps or both may underlie many cases of allergy-related hyposmia.

Whiplash injuries of the cervical spine comprise 30% of injuries reported following motor vehicle accident (MVA) and often progress to chronic painful conditions. The purpose of this case report is to describe the management of a 37-year-old female referred to physical therapy with neck and shoulder pain after whiplash injury. The patient demonstrated limited cervical and shoulder active range of motion as well as quantitative sensory testing (QST) results consistent with central nervous system sensitization. She was treated for 11 visits over a 6-week period with manual therapy and specific exercise directed to the cervicothoracic spine. Her pain decreased from 9/10 to 2/10 by the end of treatment and remained improved at 1/10 at the 6-month follow-up. Her Copenhagen Neck Functional Disability Scale decreased from 23/30 to 4/30 by the 11th visit. In addition, she demonstrated clinically significant increases in cervical active range of motion and normal somatosensation. Manual therapy of the cervicothoracic spine may be a beneficial adjunct to the standard care of patients with signs and symptoms of central sensitization after whiplash-associated disorder and primary report of neck and shoulder pain.

Pain is a common complaint among clients seeking physical therapy services, yet interpretation of associated sensory changes can be difficult for the clinician. Musculoskeletal injury typically results in nociceptive pain due to noxious stimuli of the damaged muscle or joint tissues. However, with progression from acute to chronic stages, altered nociceptive processing can give rise to an array of sensory findings. Specifically, patients with chronic joint injury may present with signs and symptoms typically associated with neuropathic injury, due to changes in nociceptive processing. Clinical presentation may include expansion of hyperalgesia into adjacent and remote areas, allodynia, dysesthesias, and perceptual deficits. Quantitative sensory testing (QST) may provide an objective method of examining sensation and, thereby, of recognizing potential changes in the nociceptive pathways. The purpose of this paper is to provide an overview of altered nociceptive processing and somatosensory changes that may occur following a musculoskeletal injury without associated neural injury. Recommendations are made on clinical uses of quantitative sensory testing in orthopaedic physical therapy practice, and supporting clinical and laboratory evidence are presented. Examples related to joint injury are discussed, specifically, osteoarthritis of the knee and low back pain. Quantitative sensory testing may be a useful clinical tool to aid clinical decision making and for determination of prognosis.

A number of non-oral causes for oral malodor have been discussed. Several well documented etiologies for non-oral malodor include renal failure, cirrhosis of the liver, and diabetes mellitus. Each of these conditions has been examined using analytical instrumentation. In addition there appear to be several other metabolic conditions involving enzymatic and transport anomalies (such as trimethylaminuria) which lead to the systemic production of volatile malodors that manifest themselves as halitosis and/or altered chemoreception. Our studies include patients who have been referred to us after being examined by numerous clinical specialists with no identification or relief from their problem. This is due in part to the intermittent nature of many of these problems as well as an apparent lack of knowledge concerning many of these metabolic problems and their relation to oral symptoms.

• As part of the developmental process for the Head and Neck Intergroup trial of adjuvant chemotherapy for advanced resectable head and neck carcinoma, in 1981 the Radiation Therapy Oncology Group, Philadelphia, Pa, conducted two nonrandomized pilot studies using chemotherapy consisting of three courses of cisplatin and fluorouracil infusion. Chemotherapy was administered prior to surgery in 42 patients (induction) and after surgery in an additional 29 patients (sequential). The populations were roughly comparable with respect to tumor site and stage. Twelve of the 42 patients in the induction group and seven of the 29 in the sequential group are alive and with no evidence of disease at the last reported follow-up. The median survival was 31 months in the sequential group vs 20 months in the induction group. Only two of the 26 patients with less than a complete clinical response following induction chemotherapy are still alive. Twenty-seven of the 42 patients who received induction chemotherapy did not undergo surgery as initially planned. Despite the lack of surgery, at 5 years the survival between the two groups was not significantly different (27% for the induction group vs 23% for the sequential group). ( Arch Otolaryngol Head Neck Surg . 1991;117:288-291)

Social Workers worldwide who are involved in the treatment of cancer patients have at their disposal a number of different interventions which have empirically demonstrated effectiveness. Other interventions, however, may in some cases contribute to cancer patients ignoring conventional medical treatments and may exacerbate stress should cancer return or spread. It is important that the practitioner be attentive to how and under which conditions these approaches can be useful and when they may be harmful.

A case series of consecutive patients referred to physical therapy with patellofemoral pain syndrome (PFPS).Physical therapists often treat patients with PFPS, yet there is currently no consensus as to the most effective management strategies. The purpose of this case series is to describe the outcomes of patients referred to physical therapy with PFPS who were treated with a multimodal approach.Five patients were treated with a combination of thrust and nonthrust manipulation directed at the joints of the lower quarter, trunk and hip stabilization exercises, patellar taping, and foot orthotics. Outcome measures used to capture change in patient status included the Numeric Pain Rating Scale, the Kujala Anterior Knee Pain Scale, the Lower Extremity Functional Scale, and the Global Rating of Change.Five patients (median age, 15 years; range, 14-50 years) with a median duration of knee pain for 8 months (range, 3-24 months) were included in this prospective case series. Four (80%) of the 5 patients demonstrated decreased pain and a clinically significant improvement in function. These gains in function were maintained at a 6-month follow-up.Although a cause-and-effect relationship cannot be inferred from a case series, the outcomes achieved by the patients are consistent with studies incorporating manual physical therapy, exercise, patellar taping, and orthotic prescription to the management of conditions of the lower extremity. Further randomized controlled trials should be performed to determine the effectiveness of this multimodal approach for the management of individuals with PFPS.

Purpose: The University of Utah Comparative Genomic Hybridization Microarray Laboratory was one of the first US laboratories to offer comparative genomic hybridisation (CGH) microarray testing using a commercial platform in a clinical setting. Results for 1076 patients (1598 chips) are presented. Methods: The Spectral Genomics/PerkinElmer Constitutional Chip TM (targeted array), SpectralChip 2600 TM (whole genome array) and a “Combo” chip (both arrays run simultaneously) were the tests offered. Abnormal results were confirmed by an alternative method, most often fluorescence in situ hybridisation. Results: In 669 cases with known normal cytogenetics, an abnormal detection rate of 10.8% was observed, (5.3%, 12.2% and 14.1% for the Constitutional Chip TM , SpectralChip 2600 TM and Combo assay, respectively). Known copy number variants and single clone abnormalities are not included in these rates. Single clone abnormalities are reported separately. For 1076 total cases, we report an average abnormal rate of 16.9% (8.7%, 23.7% and 18.6% for the three assays). This rate includes characterisation of some abnormalities previously identified by cytogenetics. Conclusions: CGH microarray provides a likely aetiology for the clinical phenotype in many cytogenetically normal cases, and a whole genome array generally identifies copy number changes more effectively than a targeted chip alone.

The impact of smell and taste disorders on dietary habits and nutritional status has received limited research attention. This paper reports findings obtained from questionnaires and diet records completed by 40 healthy subjects and 118 patients with chemosensory dysfunction. Chemosensory disorders were frequently associated with decreases in food acceptability. Although dietary responses to these dysfunctions varied greatly, patients with distorted or phantom smell and/or taste sensations tended to report weight loss whereas those with simple sensory loss were more likely to report weight gain. Indices derived from diet records did not indicate that either group of patients was at substantial nutritional risk, but food frequency responses and estimates of body mass index were consistent with patient reports of changes in dietary patterns and weight. In addition, marked weight change and aberrant dietary practices were noted in individual patients. Thus, there were indications that chemosensory dysfunction may be associated with nutritionally important dietary alterations.

The authors examined the feasibility of using olfactory receptor neurons from living patients to test whether calcium signaling is altered in a neuronal cell population in bipolar disorder.Ratiometric fluorescence photomicroscopy was used to assess basal and stimulus-induced changes in intracellular calcium levels in biopsy-derived olfactory receptor neurons from seven euthymic patients with bipolar disorder who were medication-free, 10 euthymic patients with bipolar disorder who were treated with mood stabilizers, and 17 age- and sex-matched comparison subjects without bipolar disorder.Olfactory receptor neurons from the seven medication-free patients responded to stimuli predominantly with decreases in intracellular calcium, unlike those from the seven matched healthy subjects. Olfactory receptor neurons from patients treated with mood stabilizers were less likely to respond to stimulation than olfactory receptor neurons from medication-free patients.This study demonstrates the feasibility of using olfactory receptor neurons to examine alterations in intracellular signaling in neuronal cells from living patients. Our results, although based on a small number of subjects, suggest that altered intracellular calcium signaling in olfactory receptor neurons may be a trait of bipolar disorder.

Benign skeletal muscle neoplasms are rare, especially when compared with their malignant counterparts. Rhabdomyomas have been reported to account for only approximately 2% of all striated-muscle neop1asms.l Although it is difficult to know the true incidence of this rare tumor, up to 76% of reported noncardiac cases have been found to occur in the head and neck region.2 Rhabdomyomas can be subdivided into different groups, based on clinical and morphological differences. The purpose of this paper is to share a unique case presentation of a man who developed a recurrence of a parapharyngeal rhabdomyoma 25 years after primary surgical excision. This paper will review the literature and discuss presenting symptoms, differential diagnosis, histopathological findings, and treatment.

We present and discuss a case of lifelong tinnitus in an otolaryngologist (L.D.L.) followed by complete elimination of the tinnitus as a result of a cerebral vascular accident located in the left corona radiata. Pre- and post-CVA audiograms showed no change in hearing. A magnetic resonance imaging study of the brain documents the size and location of the lesion. Discussion looks at recent studies of the central nervous system showing evidence of increased activity related to tinnitus. Our assessment of the lesion and the resulting loss of tinnitus can be explained by the neurophysiological model of tinnitus, which includes plasticity of the central nervous system.

Summary: In the past, bilateral vocal fold immobility (BVFI) occurred most commonly after thyroidectomy. However, no large series documenting the etiology of adult BVFI has been published within the past fifteen years. This study reviews the etiologic patterns of BVFI at our institutions. We compare BVFI from before and after 1980. We also review combined studies of unilateral vocal fold immobility (UVFI) to compare and unilateral versus bilateral etiologic trends. In comparison with previously published series, fewer cases of BVFI present today as a complication of thyroid surgery and more as the result of malignancies and nonsurgical trauma. Unfortunately, BVFI caused by malignancy is not usually an initial sign of local disease, but an ominous sign of recurrence or metastases. In comparing UVFI and BVFI we found that thyroidectomy causes a higher percentage of BVFI than of UVFI. Over one-third of UVFI cases were caused by neoplasm which further underscores the potential seriousness of immobile vocal folds and the need for careful investigation.

We read with interest the papers by Schafer and colleagues1 on the classification of patients with low back and leg pain and the associated study by Walsh & Hall2 on psychological differences between subgroups within this classification scheme. We agree that the time has come for clinicians to seriously consider that leg pain associated with low back pain (LBP) is not a homogenous subgroup unto itself and consideration should be given as to whether patient signs and symptoms have a dominant neural or musculoskeletal component. These papers raise some interesting questions on which we would like to comment. In the paper by Schafer and colleagues1 we do not believe the criteria used by the authors for the “central sensitization” and “peripheral nerve sensitization” subgroups differentiates sufficiently between these categories. Schafer et al1 rely on the Leeds Assessment of Neuropathic Signs and Symptoms (LANSS) with a score of 12 or more to place patients in the central sensitization category and a series of neural provocation signs combined with palpation to place patients in the peripheral nerve sensitization category. Our understanding of the LANSS is that it was developed to identify patients that may have pain of neuropathic origin3 and we do not agree with Schafer et al1 that a score over 12 necessarily indicates that central sensitization is the dominant symptom mechanism. Spontaneous pain, burning pain, and the presence of hyperalgesia screened for in the LANSS are not exclusively found in individuals with central sensitization and have also been attributed to peripheral nerve sensitization4. In a validation study of the self administered LANSS, Bennett et al5 used patients of varying “peripheral nerve” diagnoses including diabetic neuropathy and nerve entrapment. Therefore, while a high score on the LANSS may be indicative of central sensitization, we feel this tool is not sensitive enough, nor originally intended for, diagnosis of this pain type exclusively. We also contend that the clinical signs and tests used to classify patients by authors as having a peripheral nerve sensitization could also be attributed to patients who have in fact central sensitization. Positive neural tissue provocation tests such as the straight leg raise, prone knee flexion and their pain provocative variants could also be attributed to central sensitization. Sterling et al6 proposed that positive responses to upper limb neural provocation tests in a whiplash cohort could represent a manifestation of the flexor withdrawal response due to increased excitability of the central nervous system. Positive responses to analogous tests of the lower extremity (e.g. straight leg raise) may represent nerve trunk sensitivity as the authors claim, but could also be explained by the mechanism described by Sterling et al6. The other criterion that Schafer et al1 use to classify patients as peripheral nerve sensitization is pain on palpation of nerve trunks. It is questionable whether or not this finding assists in meaningful differentiation between the two pain mechanisms as elicited tenderness on palpation could be an area of secondary hyperalgesia and hence be attributed to part of a central sensitization pain mechanism just as easily as peripheral sensitization as the authors propose7. Therefore we believe that neural provocation tests and palpation by themselves lack the sufficient sensitivity to discriminate between these two types of pain mechanisms. Perhaps it is this difficulty in differentiation that in part explains the surprising subgroup differences that were reported by Walsh & Hall2. The authors report that the peripheral sensitization subgroup had significantly higher Oswestry Disability, pain, anxiety and Fear Avoidance Belief Questionnaire scores than all the other subgroups described by Schafer et al1. We share their surprise at these findings and agree with the expectation that these measures would be significantly higher in the centralization subgroup. We feel these findings serve to underscore our point that the criteria for the described classification scheme do not clearly differentiate between the subgroups per the proposed mechanisms.

Renewed attention to chemosensory dysfunction has revealed that a substantial portion of the population are affected during their lives, many simply as a result of aging. The authors discuss terminology, assessment, etiology, and prognosis and compare current understanding with that presented by Mackenzie in 1884.

To determine whether elapsed radiation therapy treatment time relates to survival in patients with head and neck cancer treated sequentially with chemotherapy and radiation therapy.From 1981 to 1988, 76 adult patients with bulky stage II-IV head and neck cancer received induction chemotherapy (fluorouracil and cisplatin). Those with a complete or partial response (n = 46) received full-dose definitive radiation therapy (range, 64.0-77.5 Gy; median, 70 Gy). Those with less than a partial response (n = 21) underwent surgery and postoperative radiation therapy (n = 15), palliative radiation therapy (n = 4), or palliative chemotherapy (n = 2). Nine patients refused to undergo radiation therapy after induction chemotherapy.The 5-year overall survival rates were as follows: 32% in all patients, 38% in patients who underwent chemotherapy and radiation therapy, and 27% in patients who underwent chemotherapy, surgery, and radiation therapy. The number of days between radiation therapy treatments was highly predictive of overall survival. In the groups with treatments less than 55 days apart, 56-65 days apart, and more than 66 days apart, the 5-year survival rates were 56%, 46%, and 15%, respectively (P = .02).The time between radiation therapy treatments is strongly predictive of survival in patients undergoing sequential chemotherapy and radiation therapy. The use of induction chemotherapy does not negate the need to avoid treatment interruptions during definitive radiation therapy.

Olfactory neuroblastoma (ONB) is a rare neuronal malignancy of the olfactory mucosal. Markers used in the diagnosis of ONB do not distinguish ONB from other neuronal tumors or tumors with neuroendocrine features thus making the diagnosis of ONB difficult. Using a modified RT-PCR technique, we show that the human homologue of the Drosophila achaete-scute gene HASH1 is expressed in 6 primary and one metastatic ONB specimens, whereas Olfactory Marker Protein (OMP) is not. Previous studies have shown that HASH1 is expressed in immature olfactory neurons and is required for their development. OMP, whose function is unknown, is expressed exclusively in mature olfactory neurons. Together, these data suggest that ONB is derived from immature olfactory neurons of neuroectodermal origin. Analysis of RNA expression in primary tumor specimens and in an established cell line make this an ideal system to study olfactory growth and differentiation. Furthermore, these studies represent the first molecular genetic analysis of this rare and unusual neuronal tumor.

An unusual localization of intranasal angiomyolipoma is described in an adult male patient with no signs of tuberous sclerosis. The lesion was composed of mature fat cells, vascular spaces with lack of elastic tissue, and presence of bundles of mature smooth muscle cells. Antibodies to intermediate filaments revealed presence of vimentin and absence of desmin in both smooth muscle bundles and in vessel walls. A review of the literature has shown that this is only the third reported case of the angiomyolipoma of the nasal cavity, and some important differences between this entity and renal angiomyolipoma are described.

Introduction: Follow-up of individuals treated for a primary squamous carcinoma of the upper aerodigestive tract is critical because of the high risk of development of either recurrent disease or a new primary tumor. A mail survey of physicians actively practicing head and neck surgery was undertaken. Materials and Methods: A multiple-choice survey was distributed to 400 members of the American Society for Head and Neck Surgery. Respondents indicated approach to post-treatment follow up. Results : Surveys were returned from 290 members (73%). Routine monthly follow up is advocated by 73% of respondents during the first postoperative year. Patients are followed every 2 to 3 months in the second postoperative year by 90% of respondents. During postoperative years, 3 to 5 patients are seen every 4 to 6 months by 97% of respondents. All respondents see patients either semiannually or annually for the remainder of their lives. Sixty percent of respondents advocate annual screening chest radiographs, whereas 14% do not order routine chest radiographs. The overwhelming majority of respondents reserve barium swallow and computed tomographic (CT) scans for evaluation of symptomatic patients. Similarly, nuclear imaging is reserved for patients with specific symptoms or abnormal laboratory tests. Blood tests most frequently monitored include complete blood cell count (CBC) (43%), thyroid function test (22%), and liver function test (20%). Follow-up endoscopic evaluation under anesthesia is reserved for symptomatic patients by over 95% of respondents. Conclusion: These data demonstrate that head and neck surgeons rarely use supplemental studies other than chest radiography during routine follow up. The authors speculate that routine chest radiography may be valuable in screening for a second primary carcinoma. Techniques to screen for esophageal tumors remain contentious.

This is a report of a 10-year median follow-up of a randomized, prospective study investigating the optimal sequencing of radiation therapy (RT) in relation to surgery for operable advanced head and neck cancer. In May 1973, the Radiation Therapy Oncology Group (RTOG) began a Phase III study of preoperative radiation therapy (50.0 Gy) versus postoperative radiation therapy (60.0 Gy) for supraglottic larynx and hypopharynx primaries. Of 277 evaluable patients, duration of follow-up is 9-15 years, with 7.6% patients lost to follow-up before 7 years. Loco-regional control was significantly better for 141 postoperative radiation therapy patients than for 136 preoperative radiation therapy patients (p = 0.04), but absolute survival was not affected (p = 0.15). When the analysis was restricted to supraglottic larynx primaries (60 postoperative radiation therapy patients versus 58 preoperative radiation therapy patients), the difference for loco-regional control was highly significant (p = .007), but not for survival (p = 0.18). In considering only supraglottic larynx, 78% of loco-regional failures occurred in the first 2 years. Thirty-one percent (18/58) of preoperative patients failed locally within 2 years versus 18% (11/60) of postoperative patients. After 2 years, distant metastases and second primaries became the predominant failure pattern, especially in postoperative radiation therapy patients. This shift in the late failure pattern along with the increased number of unrelated deaths negated any advantage in absolute survival for postoperative radiation therapy patients. The rates of severe surgical and radiation therapy complications were similar between the two arms. Because of an increased incidence of late distant metastases and secondary primaries, additional therapeutic intervention is required beyond surgery and postoperative irradiation to impact significantly upon survival.

Recovery from temporary threshold shift (TTS) was measured for a subject with normal hearing following exposures to a continuous pure tone 1000 Hz and white noise. The intensity of the exposure tone was 123, 117, and 110 dB SPL and the exposure duration was 21, 10, and 10 min, respectively. The intensity and duration of exposure to white noise were 123 dB SPL and 30 min. Automatic audiometer was used to obtain TTS and recovery at a frequency 1500 Hz measured from 1 min to 51 days, 6 days, and 23 h after exposures to 1000 Hz. For white noise, TTS and recovery were measured from 1 to 25 min. Results indicated that, (1) there was steady progression of recovery to pre‐exposure threshold, and (2) recovery was neither a simple linear nor monotonic process. These results were compared with our previous study of TTS and recovery obtained at various frequencies following exposures to pure tones 250 and 1000 Hz.

Temporary threshold shift was measured by Bekesy audiometry in subjects with normal hearing and sensorineural hearing impairment. The 20‐dB SL exposure of 1‐min duration at 4000 Hz resulted in similar shift for the same exposure frequency as 80‐dB SL exposure in a normal subject. This finding is in good agreement with results of Lierle and Reger, Hirsh, and Bilger. When the exposure level was higher than 90 dB SPL, shift at a frequency 1/2 octave above the exposure frequency exceeded that produced at the exposure frequency. The 20‐dB SL (77‐dB SPL) and 30‐dB SL (87‐dB SPL) exposures of 1 and 3 min durations at 4000 Hz for a subject with sensorineural loss showed similar shift as in a normal subject. It is assumed that the area of basilar membrane affected by adaptation remainder is smaller after an exposure to 20 dB SL than to 80 dB SL. Since adaptation is maximal for a given neurone, those neurones concerned with threshold intensities are adapted equally for both 20 and 80 dB. During adaptation remainder...

Injection of Teflon® paste is a commonly accepted procedure to improve the caliber of voice in unilateral vocal cord paralysis. There are several drawbacks to Teflon injection, among them respiratory obstruction (from overinjected Teflon) and unsatisfactory voice quality (Teflon causes stiffness of the vocal folds). This paper is a preliminary report on lipoinjection instead of Teflon injection into a paralyzed vocal fold. Fat appears to impart a soft bulkiness to the injected cord, while allowing it to retain its vibratory qualities. It is autologous material and can be retrieved if excessively overinjected. The fate of autologous fat injected into a paralyzed vocal cord remains unknown. Most of the literature on lipoinjection concerns repairs of depressed scars or breast augmentation. Our longest follow-up has been 12 months. Three patients have had this procedure, and the results appear to be very encouraging.

Interrupted pure‐tone threshold measurements were made monaurally by Bekesy audiometry with and without presentation of inaudible identical continuous stimulus and white noise on subjects with bilateral normal hearing and unilateral sensorineural hearing loss with and without abnormal auditory threshold adaptation. Thresholds were compared for interrupted stimulus only and both interrupted stimulus and inaudible stimulus presentation. Subjects with normal hearing and sensorineural hearing loss without abnormal adaptation showed no difference with and without presentation of the inaudible continuous stimulus. Subjects with sensorineural hearing loss demonstrating marked abnormal adaptation revealed observable threshold shift for the interrupted stimulus by adding inaudible stimulus. It is assumed that the inaudible stimulus affecting partially damaged nerve fibers produce widespread abnormal adaptation that the threshold for another signal is inaudible until an abnormally high intensity is reached. A stimulus incapable of evoking a response may cause adaptation in such fibers.

Recovery from temporary threshold shift (TTS) was measured for a subject with normal hearing following exposures to pure tones 250 and 1000 Hz. The intensity of the exposure tones was 125 and 123 dB SPL and duration was 30 and 21 min for 250 and 1000 Hz, respectively. Bekesy audiometer was used to obtain TTS and recovery at continuously variable frequencies between 100–10 000 Hz. Recovery of auditory threshold was measured at selected frequencies from 1 min to 47 h after an exposure to 250 Hz and from 1 min to 51 days after an exposure to 1000 Hz. Results indicated that (1) there was the greatest TTS at frequencies around 1/2 octave above the exposure frequency, (2) there was steady progression of recovery to pre‐exposure threshold at all selected frequencies, and (3) recovery was neither a simple linear nor monotonic process.

The authors present a case of a highly atypical, possibly malignant, hibernoma. It presented as a deep-seated tumor in the retropharynx of a 57-year-old male. A review of possible similar cases is presented. The patient is without recurrence 4 years after complete excision and radiation therapy. The tumor must be differentiated from liposarcoma. The clinical potential must await the accumulation and observation of additional cases.

Hydrostatic pressure changes in endolymph as well as perilymph and cerebrospinal fluid (CSF) following intravenous injection of glycerol, urea, and mannitol were studied in the guinea pig using a servo-controlled micropipet system. After the initial rise in pressure observed during and immediately after injection of each hyperosmotic agent, all pressures fell below baseline levels for about 20 minutes. The largest reductions in pressure with each of the hyperosmotics showed no significant difference between CSF and labyrinth. In the glycerol and urea studies, labyrinthine pressures stabilized at their minimum levels 20 to 40 minutes after injection, while CSF pressure recovered slowly. However, alteration of labyrinthine pressures induced by mannitol paralleled that of CSF. These results may suggest a possible osmotic dehydration effect in the labyrinth for glycerol and urea, but an ambiguous effect for mannitol.

— One hundred persons were selected from our audiology records who showed at least 20 dB bilateral sensorineural hearing loss. The number 100 was picked for an adequate statistical analysis. The patients were taken from the chart files which are filed in chronological order. Letters were mailed with instructions for fasting 14 hours prior to testing except for the consumption of water. On presentation, a history was taken for diabetes, height and weight, and the blood pressure was recorded. The blood samples were drawn in clot tubes and taken to a commercial laboratory for overnight refrigeration and testing of the serum. Testing included observation of serum for massive chylomicronemia, triglycerides, cholesterol and lipoprotein electrophoresis (by the cellulose acetate method). Lipoprotein testing results showed 12 patients with Type II A or II B and 8 patients with Type IV abnormalities. No Types I, III or V were found. These 20 patients represent a lower number of hyperlipoproteinemic patients than would be expected in the general population.