In-office Use Research Articles

At-Home "Tips" for Headache Management: The Use of Self-Trendelenburg to Help Determine the Cause of Worsening Headaches - A Case Series.

In-office use of the Trendelenburg position has been shown to be a beneficial clinical tool to help decipher if a CSF pressure/volume component is part of the underlying etiologic process for a patient's persistent headache. Utilizing the Trendelenburg position at home could potentially be an additional diagnostic tool for the treating headache physician. Our headache practice has been using at-home self-Trendelenburg for the past 2 years and will present the clinical scenarios in which it seems to be the most helpful utilizing a case series of patients. These include (1) in those who just had a lumbar puncture and call for worsening headaches and do not have an obvious orthostatic component; (2) in those who had a spinal epidural blood patch for a presumed CSF leak and state there was no improvement; (3) in those who are on daily preventive CSF volume-lowering medications and call in with worsening headaches; (4) in those with known CSF pressure-dependent headaches high or low but who are not on daily preventive CSF volume modulatory medications; (5) in those with a history of migraine or other primary headache disorder to see if a new type of headache is possibly from a CSF leak or an abnormal reset of CSF pressure to an elevated state; (6) in those with triggered only headaches like cough or exertional headache. Utilizing at-home self-Trendelenburg can provide valuable information for the treating headache physician on possible underlying headache etiology and can guide specific treatment strategies. Its simplicity and quick declaration of results are very patient pleasing.

A Practical Guide to Measuring Optic Disc Size and its Clinical Correlation in Diagnosing Glaucoma for the Eye Care Professional

This study examines the connection between glaucoma and the optic disc, cup, and neuroretinal rim size. The use of a slit-lamp and funduscopy lens as a technique for determining and estimating the optic disc size is particularly emphasized. Through this study, a clinical manual for working clinicians will be developed by summarizing this information and making it easily accessible for in-office use. PubMed, Science Direct, Ovid, Medline journals, and inter-library journals were used to find papers and abstracts of relevant studies for this review. The most common search terms were: procedures for assessing optic disc size, variance in optic disc size between populations, and ophthalmoscopic methods for measuring optic discs. The search period spanned 2020 to 2022. The following criteria were used to determine whether an article should be included or excluded: a critical evaluation of the various methods used to measure the optic disc, the significance of including population-specific variations in the size of the optic disc, and justifications for the relative risk of glaucoma associated with the size of both the optic disc and the optic cup. According to numerous studies, a slit lamp and funduscopy lens can be used to estimate the size of the optic disc. Additionally, this review discovered a weak association between measures taken at a slit lamp and those taken with more exact office tools, including fundus photography. Using fundoscopic technologies is an effective and affordable method for measuring the optic nerve head while retaining a high level of accuracy. These dimensions can be used to divide the sizes of optic discs into three groups: small, average, and large.

Effectiveness and cytotoxicity of two desensitizing agents: a dentin permeability measurement and dentin barrier testing in vitro study

BackgroundWhen evaluating the efficacy and safety of various desensitizing products in vitro, their mechanism of action and clinical utility should be considered during test model selection. This study aimed to evaluate the effects of two desensitizers, an in-office use material and an at-home use material, on dentin specimen permeability, and their dentin barrier cytotoxicity with appropriate test models.MethodsTwo materials, GLUMA desensitizer (GLU) containing glutaraldehyde and remineralizing and desensitizing gel (RD) containing sodium fluoride and fumed silica, were selected. Human dentin specimens were divided into three groups (n = 6): in groups 1 and 2, GLU was applied, and in group 3, RD was applied and immersed in artificial saliva (AS) for 24 h. Dentin specimen permeability before and after each treatment/post-treatment was measured using a hydraulic device under a pressure of 20 cm H2O. The perfusion fluid was deionized water, except in group 2 where 2% bovine serum albumin (BSA) was used. The representative specimens before and after treatment from each group were investigated using scanning electron microscopy. To measure cytotoxicity, test materials were applied to the occlusal surfaces of human dentin disks under which three-dimensional cell scaffolds were placed. After 24-h contact within the test device, cell viability was measured via 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assays.ResultsGLU significantly reduced the dentin permeability and occluded the dentinal tubules when 2% BSA was used as perfusion fluid. RD significantly reduced dentin permeability and occluded the tubules, but permeability rebounded after AS immersion. GLU significantly decreased cell viability, but RD was non-cytotoxic.ConclusionsIn vitro GLU application induced effective dentinal tubule occlusion only following the introduction of simulated dentinal fluid. RD provided effective tubule occlusion, but its full remineralization potential was not realized after a short period of immersion in AS. GLU may harm the pulp, whereas RD is sufficiently biocompatible.

Indications for absorbable steroid-eluting sinus implants: Viewpoint via the Delphi method.

Absorbable steroid-eluting sinus implants provide targeted corticosteroid release over a sustained period and are designed to prevent both undesirable adhesion formation and sinus ostia restenosis. Here, we highlight the key evidence of these implants to date and query a group of experts via a Delphi process on the indications and optimal timing for intraoperative or in-office placement of these implants. Six of a total of 12 statements reached consensus and were accepted. Overall, experts largely agree that intraoperative or in-office use of steroid-eluting stents could be considered for patients: (1) who are diabetic or intolerant of oral steroids, (2) undergoing extended frontal sinus surgery, and (3) with recurrent stenosis. Given the lack of expert consensus on other key statements, clinicians should carefully consider these treatment options on a case-by-case basis after shared decision-making.

Anatomic Optical Coherence Tomography (aOCT) for Evaluation of the Internal Nasal Valve.

To establish the utility of anatomic optical coherence tomography (aOCT) in evaluating internal nasal valve (INV). Anatomic specimen imaging study. Fresh-harvested human specimen heads were evaluated using both computed tomography (CT) imaging as well as using aOCT. Scans were performed at three time points: 1) After septoplasty for cartilage harvest, 2) after placement of butterfly graft (BFG), and 3) after placement of bilateral spreader grafts (SG). Imaging data were then converted into 3D models of the nasal airway. CT- and aOCT-generated models were compared by both static volumetric analysis and computational fluid dynamics (CFD) to predict nasal resistance and pressure. Scans using aOCT showed comparable results to CT in terms of volumetric parameters both before and after intervention. Analysis of aOCT data by CFD demonstrated decrease in pressure after SG or BFG intervention. No statistically significant difference was observed when comparing CT- and aOCT-generated calculations of pressure or resistance. The INV can be imaged in a static fashion using aOCT technology. Advantages over traditional CT imaging include lack of exposure to radiation and rapid scan time. In addition, in-office use is possible as aOCT technology develops. Further investigation will be necessary to define the role of aOCT in the dynamic evaluation of this vital component of the nasal airway. 3 Laryngoscope, 132:2148-2156, 2022.

Color change after tooth bleaching with ozone and 10% ozonized carbamide peroxide for in-office use.

There is a constant search for bleaching treatments that can offer greater safety with fewer adverse effects, especially in the techniques performed in the office, which usually employ hydrogen peroxide in high concentrations (35% to 40%) that are not recommended by some international control agencies. This in vitro study evaluated the color change after tooth bleaching with the use of ozone and a 10% ozonized carbamide peroxide bleaching treatment for in-office use. Thirty molars were allocated (n = 10): three applications of ozone (1 hour every 3 days); three applications of 10% ozonized carbamide peroxide (1 hour every 3 days); 10% carbamide peroxide agent (8 hours a day for 7 days). The teeth were mounted on a plaster model to simulate the dental arch, and trays made of silicone were used for the application of the bleaching agents and to allow ozone to enter through. The ozone concentration used was 60 μg/mL, with an oxygen flow of 0.25 L/min. The values of color change showed no significant differences among treatments. The variations in the parameters over time, as well as the values of ΔEab, ΔE00, and WID, showed that there was no significant difference among the three treatments. The use of ozone and 10% ozonized carbamide peroxide for in-office use was effective for tooth bleaching with clinically perceptible and acceptable color alterations. The study was approved on September 10, 2019 by the São Leopoldo Mandic Ethics Research Committee (CAAE No. 17711719.4.0000.5374).

S0498 Validation of a Point of Service, Disposable Rectal Expulsion Device (RED) to Identify Constipated Individuals With an Evacuation Disorder

INTRODUCTION: More than a third of chronically constipated patients who fail to improve with laxatives have an evacuation disorder. Balloon Expulsion Testing (BET) is an effective means of identifying patients with an evacuation disorder. Currently available BET devices are not designed for point of service use and require a separate visit to a GI physiology laboratory. To bring testing for an evacuation disorder to any community gastroenterologist, we created a disposable, self-inflating Rectal Expulsion Device (RED) which is intended for in-office use. We compared results and comfort of RED with a predicate, commercially available BET. METHODS: Six healthy volunteers (HVs) & 14 CC patients underwent BET and RED from September 2019 to November 2019. HVs had no GI symptoms. CC patients had significant constipation symptoms despite laxative therapy. Each subject underwent BET (Mui Scientific, Mississauga, Ontario) and RED in randomized order. An abnormal test was defined as the inability to pass the BET device (50 ml water filled balloon) or RED in < 60 seconds. If a subject was unable to pass BET or RED after 120 seconds, it was removed by the investigator. Following BET & RED, each subject self-reported device smoothness (SM), shape (SH), size (SZ), overall comfort (OC), and procedure duration (PD) (1 = Unbearable and 10 = Highly Acceptable). Kappa (k) and independent t-tests were performed. P-values <0.05 were considered statistically significant. RESULTS: Mean age of subjects was 50.2 ± 12.3 years (Range: 28-76). Most subjects were female (95.0%) & Caucasian (85.0%). Using a normal threshold of 60 sec, device agreement between BET & RED was 100% (Table 1). All HVs had normal BET & RED. For the entire study cohort, 11/20 (55.0%) had an abnormal BET and RED. Mean time to device passage in those with an abnormal BET was 119.1 (SD = 3.1) seconds & 116.4 (SD = 12.1) seconds for RED (P = 0.45). For those with a normal test (45.0%), the mean time to expel BET or RED were similar (24.8 seconds; SD = 14.3 vs. 14.7 seconds; SD = 6.0, P = 0.14). There were no significant differences in patient-perceptions of BET or RED (Table 2). CONCLUSION: RED offered excellent test agreement with a commercially available BET device. RED will allow community gastroenterologists an easy, quick test to identify constipated patients with an evacuation disorder who are most likely to benefit from biofeedback training rather than continued laxative therapy.Table 1Table 2

The Efficiency and Acceptance of a Suction Tongue-Cleaning Device in Adults

Halitosis is often caused by a change in the oral biofilm, primarily located on the surface of the tongue. A suction tongue cleaner enables professional cleaning of the tongue. The aim of this study was to investigate the acceptance and efficiency of a suction tongue-cleaning device in adults in comparison to a conventional manual tongue cleaner in an office (professional) setting. Both were tested simultaneously on 100 individuals with a split-mouth (i. e. half-tongue) design, between the ages of 19 to 31, at the University Center for Dental Medicine Basel UZB. To evaluate the efficiency of the cleaning, photos were taken before and after the cleaning and later assessed by using a modified coating tongue index by Winkel (WTCI). Both cleaning devices significantly reduced the coating on the tongue (p < 0.001). In 58 cases, the side cleaned with the suction tongue cleaner resulted to be cleaner in comparison to the side which was cleaned manually. There were no significant differences in acceptance on a visual analogue scale (VAS, 0-10 cm) between the devices (p = 0.259). However, 53 subjects favored the manual method in comparison to 36 who favored the suction device. The remaining 11 did not convey any preference for either. Both devices triggered an equally frequent gag stimulus. With 95%, the majority of the patients who had this treatment would undergo it a second time. In conclusion, both cleaning devices resulted in a significant reduction of tongue coating, and the usage in general can be highly recommended. While it does not matter which one is used, the suction tongue-cleaning device offers a good alternative to manual tongue-cleaning devices in dental clinics and can be considered a viable adjunct for in-office use.

The Efficiency and Acceptance of a Suction Tongue-Cleaning Device in Adults

Halitosis is often caused by a change in the oral biofilm, primarily located on the surface of the tongue. A suction tongue cleaner enables professional cleaning of the tongue. The aim of this study was to investigate the acceptance and efficiency of a suction tongue-cleaning device in adults in comparison to a conventional manual tongue cleaner in an office (professional) setting. Both were tested simultaneously on 100 individuals with a split-mouth (i. e. half-tongue) design, between the ages of 19 to 31, at the University Center for Dental Medicine Basel UZB. To evaluate the efficiency of the cleaning, photos were taken before and after the cleaning and later assessed by using a modified coating tongue index by Winkel (WTCI). Both cleaning devices significantly reduced the coating on the tongue (p < 0.001). In 58 cases, the side cleaned with the suction tongue cleaner resulted to be cleaner in comparison to the side which was cleaned manually. There were no significant differences in acceptance on a visual analogue scale (VAS, 0-10 cm) between the devices (p = 0.259). However, 53 subjects favored the manual method in comparison to 36 who favored the suction device. The remaining 11 did not convey any preference for either. Both devices triggered an equally frequent gag stimulus. With 95%, the majority of the patients who had this treatment would undergo it a second time. In conclusion, both cleaning devices resulted in a significant reduction of tongue coating, and the usage in general can be highly recommended. While it does not matter which one is used, the suction tongue-cleaning device offers a good alternative to manual tongue-cleaning devices in dental clinics and can be considered a viable adjunct for in-office use.

The Role of Peroxide Based Bleaching Agents in the Induction of Tooth Sensitivity

Tooth whitening is increasingly requested lately due to increased aesthetic demands of patients. The aim of our study was to analyse if there are differences, in terms of tooth sensitivity, between at-home and in-office bleaching agents used in tooth whitening, and also, if a higher concentration of bleaching agents leads to increased the tooth sensitivity. We used four bleaching agents in our study, two at-home use (Opalescence PF �Ultradent, with 10% and 20% concentration), and two in-office use (Opalescence Boost 40% - Ultradent and Pola Office 35% - SDI). The studied patients (161) were divided into four groups, after the used bleaching agent. After the tooth whitening procedures, the patients were recalled twice a week for two weeks, so that we conducted four sessions of determining the tooth sensitivity. The results showed that the patients with higher tooth sensitivity were from those with at-home whitening procedures, with a lower concentration of the peroxide-based bleaching agents.

In-Office Use of a Steroid-Eluting Implant for Maintenance of Frontal Ostial Patency after Revision Sinus Surgery

Achieving long-term, successful outcomes with endoscopic sinus surgery (ESS) can be challenging in patients with recalcitrant chronic rhinosinusitis (CRS). Local complications, including scar formation and ostial stenosis, can lead to recurrent blockage and subsequent relapse. The frontal sinus is particularly vulnerable to surgical failure given its narrow outflow and inaccessibility to topical therapies. The advent of steroid-eluting sinus implants has enhanced ESS outcomes, with significant reductions in synechiae, inflammation, and secondary postoperative interventions when placed in the ethmoid cavity. However, use of this technology in the frontal sinus has yet to be described. The purpose of this report is to present two cases, in which in-office frontal placement of a mometasone furoate (MF)-eluting implant facilitated maintenance of ostial patency after revision ESS. The clinical presentation, in-office intervention, and treatment outcomes were examined. Two patients (male, 63 and 68 years of age) with a history of multiple ESS presented with recurrent unilateral frontal headache refractory to medical therapy. Nasal endoscopy/imaging revealed frontal sinus outflow obstruction. Both declined revision ESS under general anesthesia and underwent endoscopic frontal sinustomy/ostial dilation in the clinic. A MF-eluting implant was placed in the frontal sinus at the end of the procedure, with preservation of ostial patency upon last follow-up at 3 and 11 months, respectively. In-office placement of a MF-eluting implant successfully maintained frontal ostial patency in patients with a history of multiple ESS. Additional randomized trials are necessary to determine statistical significance, cost-effectiveness analysis, and long-term efficacy of frontal sinus implantation.

α1 Antitrypsin deficiency: current best practice in testing and augmentation therapy.

α1 Antitrypsin deficiency (AATD) increases the risk of chronic obstructive pulmonary disease (COPD), liver disease and other conditions. Although it is not a rare disease, it is a condition rarely diagnosed because of unawareness by most healthcare providers who manage subjects at risk. Testing recommendations have been published and strongly suggest testing all subjects with confirmed COPD, cryptogenic liver cirrhosis, subjects with incompletely reversible airflow obstruction and siblings of affected individuals. Testing strategies usually imply a combination of measures of α1 antitrypsin (AAT) levels, phenotyping and genotyping, techniques that have been facilitated for in-office use by development of testing kits using dried blood spots. Early detection of subjects is crucial to apply effective preventive measures and early institution of therapy. The only specific Food and Drug Administration - approved therapy for this condition is lifelong weekly intravenous AAT replacement (augmentation therapy). Observational studies strongly suggest a beneficial effect of augmentation therapy in slowing lung function decline and randomized trials suggest a beneficial effect in slowing the progression of emphysema over time as measured by computed tomography. In addition, augmentation therapy has been shown to modulate systemic inflammatory responses and affect markers of elastin degradation. As new markers of disease progression are discovered, new doses of AAT replacement are tested and sub-phenotypes of disease are described, treatment recommendations are likely to change towards a more individualized therapeutic approach.

Promoting Gynecologic Cancer Awareness at a Critical Juncture—Where Women and Providers Meet

Given the absence of effective population-based screening tests for ovarian, uterine, vaginal, and vulvar cancers, early detection can depend on women and health care providers recognizing the potential significance of symptoms. In 2008, the Centers for Disease Control and Prevention's (CDC) Inside Knowledge campaign began distributing consumer education materials promoting awareness of gynecologic cancer symptoms. We investigated providers' in-office use of CDC gynecologic cancer materials and their recognition of the symptoms highlighted in the materials. We analyzed data from a national 2012 survey of US primary care physicians, nurse practitioners, and gynecologists (N = 1,380). Less than a quarter of providers (19.4%) reported using CDC gynecologic cancer education materials in their offices. The provider characteristics associated with the use of CDC materials were not consistent across specialties. However, recognition of symptoms associated with gynecologic cancers was consistently higher among providers who reported using CDC materials. The possibility that providers were educated about gynecologic cancer symptoms through the dissemination of materials intended for their patients is intriguing and warrants further investigation. Distributing consumer education materials in health care provider offices remains a priority for the Inside Knowledge campaign, as the setting where women and health care providers interact is one of the most crucial venues to promote awareness of gynecologic cancer symptoms.

Clarification/Erratum: Guidelines: In‐Office Use of Conscious Sedation in Periodontics

Journal of PeriodontologyVolume 84, Issue 4 p. 566-566 Clarification/Errata Clarification/Erratum: Guidelines: In-Office Use of Conscious Sedation in Periodontics First published: 01 April 2013 https://doi.org/10.1902/jop.2013.134003Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume84, Issue4April 2013Pages 566-566 RelatedInformation

In-office Balloon Dilation and Drainage of Frontal Sinus Mucocele

Treatment of frontal sinus disease represents one of the most challenging aspects of endoscopic sinus surgery. Frontal sinus mucocele drainage may be an exception to the rule because in many instances, the expansion of the mucocele widens the frontal sinus recess and renders surgical drainage technically undemanding. Recently, there has been an increased interest in in-office procedures in otolaryngology because of patient satisfaction and substantial savings of time and cost for both patients and physicians. Similarly, the past few years have witnessed an increased use of balloon dilation devices in sinus surgery. Previously, we have described the in-office use of this device in treating patients who failed prior conventional frontal sinusotomy in the operating room. In this report, we describe our step-by-step in-office experience using this tool for drainage of a large frontal sinus mucocele.

Kopfimpulstest und Vibrationstest in der Schwindeldiagnostik

One of the most important questions within the field of vertigo-diagnosis is the proof or the exclusion of a vestibular impairment, the spectrum of appropriate diagnostic tools has been expanded by the head impulse test and the vibratory test in the last years. The head impulse test is a method to examine the functionality of single semicircular canals. As clinical "bedside test" it is an already established part of the diagnostic procedures, as an apparative method with registration and quantitative analysis, however, it is available for general in-office use only recently. The vibratory test is a method for provoking non-spontaneous nystagmus. As a basis of a sophisticated vestibular diagnosis the test is less suitable, however, it is an absolutely valuable method to detect peripheral or central vestibular imbalances. In this regard the vibratory test is superior to other methods as for example the head shaking test. In the following article an overview concerning the physiological, methodical, and clinical aspects of the head impulse test and the vibratory test will be given.

Office Pulsed Dye Laser Treatment for Benign Laryngeal Vascular Polyps: A Preliminary Study

The 585-nm pulsed dye laser (PDL) was recently deemed relatively safe and effective for treatment of laryngeal papilloma, dysplasia, and granuloma. We report on in-office PDL treatment of laryngeal vascular polyps. Retrospective case results from 29 consecutive cases of laryngeal polyps were evaluated to determine the percent change in polyps after PDL treatment. Preoperative and postoperative measurements of polyp size, total power delivered to the site, and whether patients opted for postprocedure phonomicrosurgery were analyzed. After PDL treatment, the results varied from complete to partial resolution of the polyp. Four patients requested conventional phonomicrosurgery, and the rest had enough improvement to defer surgery. Almost 40% of patients with larger polyps desired operative intervention after laser treatment, whereas only 13% of those with small polyps opted for phonomicrosurgery. Thirty-eight percent (11 of 29) of the lesions had greater than 70% improvement after 1 or 2 laser treatments (average of 1.1 procedures). Smaller lesions responded better. Thirty-nine percent of small polyps resolved by greater than 70%, whereas only 20% of larger lesions improved by the same amount. There were no adverse events from the office procedure. In-office use of the PDL for treatment of vascular polyps may be a safe alternative to phonomicrosurgery. Small polyps seem to show a better response.

Fibrin sealant for control of cerebrospinal fluid otorrhea

Cerebrospinal fluid (CSF) otorrhea is a potentially common complication of trauma or surgery involving the temporal bone and skull base. Traditional methods of controlling CSF otorrhea include observation with or without subarachnoid lumbar drainage of CSF, reinforcement of the incision, or surgical exploration with operative obliteration of the drainage pathway. In recent years, fibrin sealants have been demonstrated to prevent intraoperative bleeding and fluid leaks in a variety of surgical specialties. Here we describe 2 cases in which application of fibrin sealant to a CSF fistula resulted in closure of the fistula without requiring surgical exploration or repair. We believe that the in-office use of fibrin sealant is a safe and costeffective method to obliterate small CSF leaks arising from the temporal bone. 2. Case 1 A 54-year-old man presented with a 4-month history of gradually decreasing hearing and increasing tinnitus in his right ear. An audiogram revealed a right profound sensorineural hearing loss with a 0% speech discrimination score. Vestibular testing revealed a right vestibulopathy, with caloric responses of the right ear 44% weaker than those of the left ear. Magnetic resonance imaging scan demonstrated an enhancing mass within the right internal auditory canal consistent with an intracanalicular acoustic neuroma. The patient subsequently underwent resection of the acoustic neuroma through a right translabyrinthine approach. The eustachian tube was packed with a plug of muscle and the incus. The operative cavity was obliterated with an abdominal fat graft, and the lateral aspect of the defect was closed with hydroxyapatite cement. On the evening of postoperative day 1, the patient experienced clear drainage from his right ear canal. A computed tomographic scan of the head was obtained, which showed complete obliteration of the mastoid cavity with fat. There was no evidence of airfluid level to suggest CSF leak, and there was no evidence of ventricular dilation. Examination of the ear failed to demonstrate a tympanic membrane (TM) perforation. The drainage was collected for analysis and subsequently tested positive for the presence of β2-transferrin, indicating a CSF leak. On postoperative day 2, the patient was given stool softeners to prevent straining and was placed on strict bed rest, with the head of his bed at 45°. A lumbar drain was placed and set to midbrain with 50 to 80 cc drainage every 8 hours. Cerebrospinal fluid otorrhea persisted despite a functioning lumbar drain. A microscope was brought to the bedside. Again, no obvious perforation in the TM was identified. The source was thought to be through the medial posterior canal wall near the annulus. The TM was covered with a layer of EpiFilm (Medtronic Xomed Inc, Jacksonville, FL), and the external auditory canal (EAC) was filled with 2 to 3 cc of Tisseel fibrin sealant (Baxter Healthcare Corp, Deerfield, IL). No further otorrhea was noted after these interventions. The lumbar drain was kept at midbrain level for 72 hours, clamped for an additional 24 hours, and then discontinued. There was no further evidence of otorrhea and no evidence of fluid accumulation under the wound. The patient was then discharged home and had no evidence of recurrent CSF leak with more than 4 years of follow-up.

In-office imaging in the care of patients with rheumatoid arthritis

The standards of 'state of the art' in-office imaging are rapidly changing. This Viewpoint assesses the imaging techniques available for in-office use and highlights the obstacles that need to be overcome in this field in order for clinicians to have easy access to the right data in order to provide the best possible care.

Pulsed Dye Laser Treatment of Laryngeal Granulomas

Laryngeal granulomas are effectively treated with antireflux therapy and speech therapy. Failure to respond leads to treatment with Botox or surgical excision. We report on the use of the pulsed dye laser for treating chronic granulomas that do not respond to standard therapy. We performed a retrospective review from September 2002 to September 2003. Patients identified with chronic granulomas that were not responding to standard therapy were treated in our office with the pulsed dye laser. Ten patients were identified; the mean age was 58 years. Two patients underwent more than one pulsed dye laser treatment. Five of the 10 had resolution of their lesions, and 3 had a partial response. Two were unchanged. The average follow-up was 6 months, and there were no complications. We conclude that in-office use of the pulsed dye laser is a relatively safe and effective method for treating laryngeal granulomas that do not respond to antireflux therapy and speech therapy.