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Munjal T, Kullar PJ, Alyono J. External Ear Disease: Keratinaceous Lesions of the External Auditory Canal. Otolaryngol Clin North Am 2023; 56:897-908. [PMID: 37550109 DOI: 10.1016/j.otc.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Keratosis obturans (KO) and external auditory canal cholesteatoma (EACC) are two distinct keratinaceous lesions of the external ear. This article reviews the signs, symptoms, pathophysiology, workup, and treatment of each. Patients with either pathology can often be managed in the clinic with debridement; however, EACC is more likely to involve osteonecrosis and require more extensive operative management if disease is not confined to the canal on account of the bony erosion characteristic of cholesteatoma. If required for extensive disease, surgical approaches to both pathologies are similar.
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Affiliation(s)
- Tina Munjal
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Palo Alto, CA 94304, USA
| | - Peter J Kullar
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Palo Alto, CA 94304, USA
| | - Jennifer Alyono
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Palo Alto, CA 94304, USA.
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Wei W, Keogh MJ, Aryaman J, Golder Z, Kullar PJ, Wilson I, Talbot K, Turner MR, McKenzie CA, Troakes C, Attems J, Smith C, Sarraj SA, Morris CM, Ansorge O, Jones NS, Ironside JW, Chinnery PF. Frequency and signature of somatic variants in 1461 human brain exomes. Genet Med 2019; 21:904-912. [PMID: 30214067 PMCID: PMC6544539 DOI: 10.1038/s41436-018-0274-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/06/2018] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To systematically study somatic variants arising during development in the human brain across a spectrum of neurodegenerative disorders. METHODS In this study we developed a pipeline to identify somatic variants from exome sequencing data in 1461 diseased and control human brains. Eighty-eight percent of the DNA samples were extracted from the cerebellum. Identified somatic variants were validated by targeted amplicon sequencing and/or PyroMark® Q24. RESULTS We observed somatic coding variants present in >10% of sampled cells in at least 1% of brains. The mutational signature of the detected variants showed a predominance of C>T variants most consistent with arising from DNA mismatch repair, occurred frequently in genes that are highly expressed within the central nervous system, and with a minimum somatic mutation rate of 4.25 × 10-10 per base pair per individual. CONCLUSION These findings provide proof-of-principle that deleterious somatic variants can affect sizeable brain regions in at least 1% of the population, and thus have the potential to contribute to the pathogenesis of common neurodegenerative diseases.
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Affiliation(s)
- Wei Wei
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Michael J Keogh
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Juvid Aryaman
- Department of Mathematics, Imperial College London, London, UK
| | - Zoe Golder
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Peter J Kullar
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Ian Wilson
- Institute of Genetic Medicine, Central Parkway, Newcastle University, Newcastle Upon Tyne, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Chris-Anne McKenzie
- National CJD Research & Surveillance Unit, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Claire Troakes
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
| | - Johannes Attems
- Institute of Neuroscience, Newcastle University, Campus for Aging and Vitality, Newcastle upon Tyne, UK
| | - Colin Smith
- National CJD Research & Surveillance Unit, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Safa Al Sarraj
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
| | - Chris M Morris
- Institute of Neuroscience, Newcastle University, Campus for Aging and Vitality, Newcastle upon Tyne, UK
| | - Olaf Ansorge
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Nick S Jones
- Department of Mathematics, Imperial College London, London, UK
| | - James W Ironside
- National CJD Research & Surveillance Unit, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
- MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge, UK.
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Kullar PJ, Gomez-Duran A, Gammage PA, Garone C, Minczuk M, Golder Z, Wilson J, Montoya J, Häkli S, Kärppä M, Horvath R, Majamaa K, Chinnery PF. Heterozygous SSBP1 start loss mutation co-segregates with hearing loss and the m.1555A>G mtDNA variant in a large multigenerational family. Brain 2019; 141:55-62. [PMID: 29182774 PMCID: PMC5837410 DOI: 10.1093/brain/awx295] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/25/2017] [Indexed: 11/30/2022] Open
Abstract
The m.1555A>G mtDNA variant causes maternally inherited deafness, but the reasons for the highly variable clinical penetrance are not known. Exome sequencing identified a heterozygous start loss mutation in SSBP1, encoding the single stranded binding protein 1 (SSBP1), segregating with hearing loss in a multi-generational family transmitting m.1555A>G, associated with mtDNA depletion and multiple deletions in skeletal muscle. The SSBP1 mutation reduced steady state SSBP1 levels leading to a perturbation of mtDNA metabolism, likely compounding the intra-mitochondrial translation defect due to m.1555A>G in a tissue-specific manner. This family demonstrates the importance of rare trans-acting genetic nuclear modifiers in the clinical expression of mtDNA disease.
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Affiliation(s)
- Peter J Kullar
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Aurora Gomez-Duran
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Payam A Gammage
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK
| | - Caterina Garone
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK
| | - Michal Minczuk
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK
| | - Zoe Golder
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Janet Wilson
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Julio Montoya
- Universidad de Zaragoza-CIBER de Enfermedades Raras (CIBERER)-Instituto de Investigación Sanitaria de Aragón, Spain
| | - Sanna Häkli
- Research Unit of Clinical Neuroscience, University of Oulu, Oulu, Finland and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Mikko Kärppä
- Research Unit of Clinical Neuroscience, University of Oulu, Oulu, Finland and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Rita Horvath
- Institute of Genetic Medicine, Newcastle University, UK
| | - Kari Majamaa
- Research Unit of Clinical Neuroscience, University of Oulu, Oulu, Finland and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Patrick F Chinnery
- MRC-Mitochondrial Biology Unit, University of Cambridge, CB2 0XY, UK.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, UK
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Kullar PJ, Quail J, Lindsey P, Wilson JA, Horvath R, Yu-Wai-Man P, Gorman GS, Taylor RW, Ng Y, McFarland R, Moore BCJ, Chinnery PF. Both mitochondrial DNA and mitonuclear gene mutations cause hearing loss through cochlear dysfunction. Brain 2016; 139:e33. [PMID: 27016405 PMCID: PMC4892749 DOI: 10.1093/brain/aww051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/03/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Peter J Kullar
- Department of Clinical Neuroscience, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK Medical Research Council Mitochondrial Biology Unit, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Jenna Quail
- Freeman Hospital, Freeman Road, Newcastle-upon-Tyne, NE7 7DN, UK
| | - Phillip Lindsey
- Freeman Hospital, Freeman Road, Newcastle-upon-Tyne, NE7 7DN, UK
| | - Janet A Wilson
- Freeman Hospital, Freeman Road, Newcastle-upon-Tyne, NE7 7DN, UK
| | - Rita Horvath
- Wellcome Trust Centre for Mitochondrial Research, Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - Patrick Yu-Wai-Man
- Wellcome Trust Centre for Mitochondrial Research, Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Grainne S Gorman
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE1 3BZ, UK
| | - Robert W Taylor
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE1 3BZ, UK
| | - Yi Ng
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE1 3BZ, UK
| | - Robert McFarland
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE1 3BZ, UK
| | - Brian C J Moore
- Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE1 3BZ, UK
| | - Patrick F Chinnery
- Department of Clinical Neuroscience, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK Medical Research Council Mitochondrial Biology Unit, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
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Kullar PJ, Sorenson K, Weerakkody R, Adams J. Case report: The management of advanced oral cancer in a Jehovah's Witness using the Ultracision Harmonic Scalpel. World J Surg Oncol 2011; 9:115. [PMID: 21967981 PMCID: PMC3204256 DOI: 10.1186/1477-7819-9-115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 10/03/2011] [Indexed: 12/11/2022] Open
Abstract
We present the first case of a head and neck oncological procedure accomplished in a Jehovah's Witness using the Ultracision Harmonic Scalpel (Ethicon, Cincinnati, OH). Jehovah's Witnesses present a serious challenge to the head and neck cancer surgeon due to their refusal to accept transfusion of any blood products. However, our experience reinforces the view that surgical management of head and neck cancer is possible in these patients. We show the Harmonic Scalpel, an ultrasonic tissue dissector, to be a useful surgical tool in obviating the need for blood transfusion. Preoperative optimisation, intra-operative surgical and anaesthetic techniques are also fully discussed.
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Affiliation(s)
- Peter J Kullar
- Department of Maxillofacial Surgery Royal Victoria Hospital Newcastle-Upon-Tyne UK.
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Guilfoyle MR, Weerakkody RA, Oswal A, Oberg I, Jeffery C, Haynes K, Kullar PJ, Greenberg D, Jefferies SJ, Harris F, Price SJ, Thomson S, Watts C. Implementation of neuro-oncology service reconfiguration in accordance with NICE guidance provides enhanced clinical care for patients with glioblastoma multiforme. Br J Cancer 2011; 104:1810-5. [PMID: 21610702 PMCID: PMC3111193 DOI: 10.1038/bjc.2011.153] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Brain tumours account for <2% of all primary neoplasms but are responsible for 7% of the years of life lost from cancer before age 70 years. The latest survival trends for patients with CNS malignancies have remained largely static. The objective of this study was to evaluate the change in practice as a result of implementing the Improving Outcomes Guidance from the UK National Institute for Health and Clinical Excellence (NICE). Methods: Patients were identified from the local cancer registry and hospital databases. We compared time from diagnosis to treatment, proportion of patients discussed at multidisciplinary team (MDT) meetings, treatment received, length of inpatient stay and survival. Inpatient and imaging costs were also estimated. Results: Service reconfiguration and implementation of NICE guidance resulted in significantly more patients being discussed by the MDT—increased from 66 to 87%, reduced emergency admission in favour of elective surgery, reduced median hospital stay from 8 to 4.5 days, increased use of post-operative MRI from 17 to 91% facilitating early discharge and treatment planning, and reduced cost of inpatient stay from £2096 in 2006 to £1316 in 2009. Patients treated with optimal surgery followed by radiotherapy with concomitant and adjuvant temozolomide achieved outcomes comparable to those reported in clinical trials: median overall survival 18 months (2-year survival 35%). Conclusions: Advancing the management of neuro-oncology patients by moving from an emergency-based system of patient referral and management to a more planned elective outpatient-based pattern of care improves patient experience and has the potential to deliver better outcomes and research opportunities.
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Affiliation(s)
- M R Guilfoyle
- Cambridge University Department of Clinical Neurosciences, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Kullar PJ, Pearson DM, Malley DS, Collins VP, Ichimura K. CpG island hypermethylation of the neurofibromatosis type 2 (NF2) gene is rare in sporadic vestibular schwannomas. Neuropathol Appl Neurobiol 2011; 36:505-14. [PMID: 20831745 DOI: 10.1111/j.1365-2990.2010.01090.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Loss of both wild-type copies of the neurofibromatosis type 2 (NF2) gene is found in both sporadic and neurofibromatosis type 2-associated vestibular schwannomas (VS). Previous studies have identified a subset of VS with no loss or mutation of NF2. We hypothesized that methylation of NF2 resulting in gene silencing may play a role in such tumours. METHODS Forty sporadic VS were analysed by array comparative genomic hybridization using 1 Mb whole genome and chromosome 22 tile path arrays. The NF2 genes were sequenced and methylation of NF2 examined by pyrosequencing. RESULTS Monosomy 22 was the only recurrent change found. Twelve tumours had NF2 mutations. Eight tumours had complete loss of wild-type NF2, four had one mutated and one wild-type allele, 11 had only one wild-type allele and 17 showed no abnormalities. Methylation analysis showed low-level methylation in four tumours at a limited number of CpGs. No high-level methylation was found. CONCLUSIONS This study shows that a significant proportion of sporadic VS (>40%) have unmethylated wild-type NF2 genes. This indicates that other mechanisms, yet to be identified, are operative in the oncogenesis of these VSs.
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Affiliation(s)
- P J Kullar
- Division of Molecular Histopathology, Department of Pathology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Sadat U, Kullar PJ, Noorani A, Gillard JH, Cooper DG, Boyle JR. Emergency endovascular management of peripheral artery aneurysms and pseudoaneurysms - a review. World J Emerg Surg 2008; 3:22. [PMID: 18644114 PMCID: PMC2494545 DOI: 10.1186/1749-7922-3-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 07/21/2008] [Indexed: 11/14/2022] Open
Abstract
Endovascular stenting has been successfully employed in the management of aortic aneurysms; however, its use in managing peripheral arterial conditions remains questionable. We review the utility of endovascular technique in the management of peripheral arterial conditions like aneurysms, pseudoaneurysms and arterio-venous fistulas in the emergency setting. Though long term data about graft patency rates is not yet available, the endovascular approach appears to be a useful minimally invasive technique in situations where open repair is either difficult or not feasible.
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Affiliation(s)
- Umar Sadat
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, UK.
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