Intradermal Vaccines

There has been good data on the efficacy of vaccines given intradermally vs subcutaneously or intramuscularly. It actually seems to function superiorly in children and the elderly. I personally take my flu shot this way as I feel it also limits my systemic side effects.   0.1 ml of both the influenza vaccine (Fluogen) and the Herpes Zoster Vaccine (Varivax) in opposite arms seems to lessen the frequency and severity of recurrent upper respiratory tract illnesses.

Scabies

I very experienced allergist and friend surprised me when he treated what I thought was just a heat rash with Permethrin.  Scabies (Sarcoptes scabiei) is an itch mite that is highly contagious.  It can be sexually transmitted for sure, but it is not always so.  It does however require close contact to spread and seems limited to humans (it is not compatible with pets).  Itching is severe and it forms papules that often blister.  Microscopy scrapings can be difficult and there is even a PCR test available.

Middle Ear Treatments

There was an interesting study on the middle ear volume, and it ended up being about 1.4 ml in non diseased individuals.  In reality, you rarely get a full ml of fluid into the middle ear when you inject it.  There is a number of reasons we put medications directly into the middle ear, such as Meneir’s Disease, sudden sensorineural hearing loss, etc…  We are typically using an anti inflammatory such as dexamethasone or an ablative medication such as Gentamycin.  Sometimes we combine the agents.  When I use the Dexamethasone, I do no dilute, and I put in as much as the middle ear will handle.  I typically anesthetize the ear with phenol or EMLA and have patient stay laying in the injection position without swallowing for 20  minutes if possible.

IMG_1966

IMG_1962

 

 

Challenging scalp lesions

Exposed calvarium represents an interesting challenge in reconstructing scalp defects.  In order to lay on a skin graft, tissue such as a temporalis flap needs to be mobilized to give a base for the graft to survive on.  Otherwise, large “pinwheel” type flaps can be constructed to close this primarily with good success.

This defect was closed with a double layer temporalis muscle flap underlying an occipitally based scalp advancement flap.

IMG_1689IMG_1863

Tongue Tie

I am reposting this because of a social media interest in what is termed “posterior tongue tie”.  It is described as a fibrous banding deep in the floor of mouth that causes feeding difficulties.  It seems to be a problem mostly manufactured by those wanting to exploit others. Most of us think of being tongue-tied as a situation where we find ourselves too excited or nervous to speak. Actually, tongue tie is a term for a relatively common physical condition that limits the use of the tongue, medically called “ankyloglossia”.

tounge_tie_mediumBefore we are born, a strong cord of tissue (the frenulum) that guides development of mouth structures is positioned in the center of the mouth. After birth, the frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins.

This frenulum is visible and easily felt if you look in the mirror under your tongue. In some children, the frenulum is especially tight or fails to recede and may cause tongue mobility problems.

The tongue is one of the most important muscles for speech and swallowing. For this reason, having tongue tie can lead to eating or speech problems, which may be serious in some individuals.  Posterior tongue tie is a nebulous term that lacks a clear definition or treatment.

Lip “Tie”

Labial Frenulectomy

Frenum_composite 1106CFP_PC_Frenum_AB-1A labial frenectomy is a form of frenectomy performed on the lip.

The labial frenulum often attaches to the center of the upper lip and between the upper two front teeth. This can cause a large gap and gum recession by pulling the gums off the bone. A labial frenectomy removes the labial frenulum. Orthodontic patients often have this procedure done to assist with closing a front tooth gap. When a denture patient’s lips move, the frenulum pulls and loosens the denture which can be uncomfortable. This surgery is often done to help dentures fit better.

The removal of the frenulum does not cause any adverse effects to the lip and mouth.  The real question is if it has any beneficial effects.

“Potential” benefits include better feeding, diminished decay of the front incisors, and avoiding a central diastema (gap in the front teeth).  I remain a bit skeptical that the benefits exist.

Challenging scalp lesions

Exposed calvarium represents an interesting challenge in reconstructing scalp defects.  In order to lay on a skin graft, tissue such as a temporalis flap needs to be mobilized to give a base for the graft to survive on.  Otherwise, large “pinwheel” type flaps can be constructed to close this primarily with good success.IMG_1689IMG_1863

Merkel-cell Carcinoma

 MERKEL CELL CARCINOMA (TOKER 1972-ENDOCRINE CA OF THE SKIN)

IMG_1692Is caused by the Merkel cell polyomavirus (MCV) 80% of the time, discovered at the University of Pittsburgh in 2008.  It is also known as a cutaneous APUDoma, primary neuroendocrine carcinoma of the skin, primary small cell carcinoma of the skin, and trabecular carcinoma of the skin.  It is a tumor of the tactile merkel cell in the stratum basale of the epidermis.  Histologically it looks like small cell lung cancer with dense cohesive sheets of highly mitotic cells with scant cytoplasm.  They are s-100 positive and are undifferentiated cells of neural crest origin.

It is a rare and aggressive neoplasm that behaves and even looks like an aggressive amelanotic melanoma.  55% present in the head and neck, 20% in the periorbital region, and  primarily in the 6th decade of life.  They are flesh colored and more than 50% overall have regional metastasis.  Surgically we treat them like a melanoma.  However, surgery alone is rarely the treatment plan as they seem to be radiosensitive.  As up to 20% may have distant metastasis at presentation, PET scanning seems appropriate.

In the past we used to say 3 cm margins with lymphoscintigraphy alone for stage 1, 40 GY radiation for stage 2, and induction chemo for stage 3.  Probably palliative chemo for stage 4.

 

Cat Scratch Disease

CAT SCRATCH Dz (CSD)—CAT SCRATCH FEVER, CAT FEVER, BENIGN INOCULATION LYMPHORETICULOSIS
RELATIVELY COMMON CAUSE OF PED CHRONIC CERVICAL LAD
PROBABLY DESCRIBED FIRST IN 1889 BY HENRI PARINAUD—PARINAUD SYNDROME IS AN ATYPICAL PRESENTATION OF CSDz
>90% Hx FELINE CONTACT(KITTENS>CATS), >50% Hx OF INOCULATION SITE—-USUALLY DISTAL (BITE OR PAPULE)
POSSIBLE TO BE CARRIED BY OTHER ANIMALS (DOGS, RABBITS, MONKEYS, FISH BONES, PORCUPINE QUILLS)
INNOCULATION—ERYTHEMATOUS RXN(MAY TAKE DAYS TO DEV.) NON-PRUTITIC/PAPULAR—-RESOLUTION WITHOUT SCARRING—2-4 WEEKS—REGIONAL LAD (OFTEN UNILAT–PRE-AURICULAR/SUBMANDIBULAR)/ LOW GRADE TEMP—-OTHERWISE ASYMPTOMATIC, CONJUNCTIVITIS, MALAISE, FATIGUE——2-3 MONTHS–SPONT RESOLUTION
SKIN OVERLYING THE LAD “PARCHMENT LIKE”
SYNDROME OF PARINAUD = UNILAT CONJUNCTIVITIS WITH LARGE PAINFUL PREAURICULAR CYSTS
Dx: Hx
ELISA OR PCR: BARTONELLA HENSLEAE (FORMERLY ROCHALIMEAE HENSLEAE) OR AFIPIA FELIS (ARMED FORCES INST OF PATH)-1991—–INTRACELLULAR M/O IN THE RICKETTSEA FAMILY
INDIRECT IMMUNOFLORESCENCE TEST AVAIL—MUST BE SENT TO OKLAHOMA CHILDRENS HOSPITAL
MILD EOSINOPHILIA
HIGH ESR
BIOPSY—-WARTHIN STARRY SILVER IMPREGNATION STAIN—-SHOWS SMALL PLEOMORPHIC G- COCCOBACILLUS
IN ANTIQUITY USED TO DO TRANSFER INOCULATION TEST (HANGER ROSE SKIN TEST) = MOLLARET-DEBRE TEST—-LIKE KVEIM-SITZBAUGH TEST
Rx: EXPECTANTLY—–TELL PTS IT HAS A VARIABLE COARSE—WOULD GIVE ZITHROMAX (PROBABLY SOME EFFICACY—NEW STUDY IT SEEMS TO REDUCE THE AMOUNT AND DURATION OF THE REGIONAL LAD)
40% MAY FORM SUPPURATIVE ADENOPATHY—-MAY DRAIN FOR SYMPTOMATIC RELIEF
MAY USE BROAD SPEC ABX TO PREVENT SUPERINFXN
MAY EXCISE OR I&D—-10% SINUS FORMATION
PROBABLY A GOOD IDEA TO COVER THE PTS WITH P.O. ABX—BUT THE ORGANISM IS INTRACELLULAR AN THUS PROTECTED EVEN THOUGH IT IS SENSITIVE

RRP and HPV

gardasil_logo_tcm1908-197175There are over 200 known serotypes of Human Papilloma Virus (HPV). About 79 million Americans are currently infected with HPV. About 7% of adults have HPV in their oral cavity. Only about 3,000 to 13,000 patients in the United States have Recurrent Respiratory Papilllomatosis (RRP). Virtually all of them have active HPV in thier oral cavity. These patients are afflicted with HPV 6 and 11, which affects primarily mucous membranes. It is looking more and more like oral to oral transmission trumps oral genital transmission. It seems to be a different animal all together than cervical HPV. Serotypes 16 and 18 are the types associated with carcinogenesis. There currently is no evidence that spouses should be vaccinated and it does not really seem to be easily transmitted between adults.  Cervarix is a bivalent 16 &18 only vaccine.

This disease has become epidemic, however the treatments and the preventative measures are also gaining momentum.  HPV is the whole reason we really did PAP smears.  The viral changes led to cervical uterine dysplasian and even carcinogenesis.  It was even suggested to consider C-section in women with active infections.

The disease is really divided into the more problematic juvenille onset (>20 lifetime surgeries) vs adult onset (<5 lifetime surgeries).  There may be some correlation with sexual behavior in adult onset, however, this is still controversial. There is no role for vaccination or even counseling or testing partners.

images-1Recurrent Laryngeal RRP may require multiple surgeries.  It seems the best initial response is with the CO2 Laser, however use of the microdebrider (PIPE) may actually give better voice outcomes

Adjuvant therapies such as Acyclovir, MTX, Ribavarin, Mumps vaccine, PPI, Alpha Interferon, Hsp E7, Retinoids, and Intralesional Cidofovir have been touted, but lack strong prospective efficacy studies.  Typically I use the CO2 laser.  Have patients eat green leafy vegetables (Indole-3-carbinols) modulates estrogen metabolism and 1/3 of patients respond.  Inject about 75 mg of Cidofovir in 1 cc after the resection.  I may consider placing on Celebrex (Cox 2 inhibitor) which modulates the over expression of epidermal growth factor by inhibiting cyclooxygenase-2 and prostaglandin E2.   I also may consider injecting Avastin (Bevacizumab) recombinant monoclonal antibody against vascular endothelial growth factor.