Rehabilitative surgery for aspiration. A clinical analysis

Operative intervention for refractory aspiration necessitates an understanding of its prognostic implications. The closure procedures most often performed are evaluated, comparing and rating technical difficulty, degree of closure, reversibility, and vocalization, both immediately and after reconstruction. The epiglottic over-sew was shown to have merit. Its distinctive features include the potential for postclosure phonation as well as the opportunity for sequential reversal. Both of these features make mastering the technique worthwhile.

Membranous basal cell adenoma of the hypopharynx

A membranous basal cell adenoma arose from the minor salivary glands in the hypopharynx of a 62-year-old man. Features distinguishing the membranous variant from other forms of basal cell adenoma include the following: (1) abundant reduplicated basement membrane material, (2) the presence of sialomucin-containing cells, and (3) the lack of distinct encapsulation. To our knowledge, this is the first report of a basal cell adenoma of the hypopharynx, and the first report of the membranous variant in a minor salivary gland.

An animal model for the assessment of microvascular patency

A tubed superficial epigastric flap (TSEF), based on a single vascular pedicle, was designed in a rat. Forty TSEFs were created in three control groups: in 20 TSEFs both the femoral artery and vein were ligated proximal to the take-off of the superficial epigastric vessels, in 10 TSEFs the femoral artery and in the other 10 the femoral vein were ligated and transected at the same location. All TSEFs in the control groups sloughed, reflecting the dependence on the axial vasculature. A further 232 TSEFs were made with a survival rate of 84.5% (196/232). Delayed arterial or venous ligation was then performed up to 42 days after the initial surgery. The patency of the axial vein was crucial for survival for only the first postoperative week. The axial arterial patency was needed for survival of the TSEF for 6 weeks. The creation of this TSEF fulfills the need for a simple model that is as readily constructed as other models, is reproducible, has a high success rate and most importantly, reflects the patency of its nutrient vessels for a prolonged period of time.

Complications of CO2 laser surgery of the larynx

The use of the surgical laser has become commonplace in many medical centers, however the limitations of its use need to be assessed. The complications of laser use are based on the physics of the instrument and the equipment used. Direct laser effects include burns of tissue unintended for lasing, and endotracheal tube (E-T) ignition. Secondary effects occur as immediate consequences of lasing, such as E-T tube obstruction, internal E-T ignition, or mucosal charring. A case of airway obstruction is presented. Delayed effects relate to healing. Suggestions are made to help avoid the outlined complications.

The importance of the pedicle for the survival of a vascularized free flap: an experimental study on rats

It has been assumed, but never shown experimentally, that the survival of a free vascularized full-thickness island flap is based on the vascular pedicle. A study using the rat was designed to assess the three parameters of flap survival: the vascular pedicle, the recipient bed, and the perimeter of the recipient area. Isolation of the pedicle by ligation caused flap necrosis in 18 out of the 20 groin flaps. An intact pedicle, with the other two parameters excluded, led to flap survival in 75% (9 of 12 flaps). Our results indicate that the critical factor to island flap survival in the immediate postoperative period is the vasculature supplying the pedicle. The two other factors are of limited importance.

Normal neonatal brainstem auditory evoked potentials

Brainstem auditory evoked potentials present a unique opportunity to assess the neuronal and auditory status of the newborn. To date, sample data have been few in number, thereby limiting their interpretive value. The present study was undertaken in an effort to accrue data generated from a large sample size. One hundred fifty-five normal neonates were tested within the first 36 hours of life. No subjects qualified for inclusion in the High Risk Register for Hearing Loss established by the American Academy of Pediatrics. Each ear was tested independently, using click stimuli at a rate of 30.1 per second at 65 dB HTL. Test runs were replicated for purposes of reliability. A run consisted of 2,000 sweeps of data, each being 10 ms in length. Identification of wave forms were assessed by two or more observers. Total agreement was required from all observers for inclusion of wave peaks for analysis. Latencies of onset of stimulus to peak were obtained. Descriptive as well as inferential statistics were computed. Results provide standardized data for comparison.

Head and neck carcinoma in patients under 40 years of age

From 1965-1978 over 2,700 patients were admitted to the Massachusetts Eye and Ear Infirmary or the Massachusetts General Hospital with carcinoma of the oropharynx, larynx or nasopharynx; only 36 of these patients were less than 40 years of age. Twelve patients had oropharyngeal carcinoma, 13 patients had laryngeal or hypopharyngeal carcinoma, and 11 patients had nasopharyngeal carcinoma. Analysis of these patients indicates an increased incidence of head and neck cancer in younger females. In patients less than age 31 there was no significant social history which contributed to early onset of disease. The younger patients with nasopharyngeal carcinoma survived longer than patients of all ages with comparable neoplasms. The survival of patients with oropharyngeal, laryngeal and hypopharyngeal carcinoma is comparable to survival in patients of all ages with similar lesions.

Peritonsillitis. Evaluation of current therapy

The records of 84 patients with peritonsillitis were reviewed. Only 19% (16) of the patients had a history of two or more notable episodes of pharyngitis. Six patients underwent an immediate tonsillectomy. The remainder of the patients was treated initially with drainage and parenteral antibiotics. Twenty-one patients underwent an interval tonsillectomy, and 57 patients had no further therapy. Of those patients who received no further therapy, 72% (41) of the patients had either one or no subsequent episodes of sore throat symptoms. Only one patient had recurrent peritonsillitis. Peritonsillitis may not necessarily be an indication for an interval tonsillectomy, and it can reasonably be managed by drainage and antibiotic therapy.

Alternatives to anterior-posterior packs for epistaxis

This paper describes two alternatives to a conventional anterior-posterior pack for control of posterior epistaxis. Both methods involve occluding the posterior choana with finger-cot packs introduced through the anterior nares. These have proved effective in controlling bleeding with significant reduced morbidity.

The association of a hearing deficit with Larsen's syndrome

A retrospective study of 45 cases of Larsen's syndrome reported since 1950 reveals a prevalence of cleft palate in this disease of about 30 per cent. Although cleft palate abnormalities in infancy invariably cause otitis media, which may result in hearing loss, only rarely have hearing deficits been reported in association with Larsen's disease. This paper reports the occurrence of a bilateral conductive hearing loss secondary to otitis media, and possible ossicular abnormality in a five-year-old with cleft palate and Larsen's disease and considers the possibility that this otologic problem may be more prevalent than currently suspected.

The evaluation of dizziness in children

A child with symptoms that relate to the balance mechanism can be a complex diagnostic problem. Often an adequate history is difficult to obtain because of the child's age and limitation of expression. Psychosomatic illness can frequently present as dizziness in children; however, this should not preclude a thorough evaluation. It is the purpose of this paper to outline these possibilities and the characteristics unique to each. The differential diagnosis can be grouped into central (central nervous system) and peripheral (otologic) categories, with a few miscellaneous conditions. A basic evaluation should include a complete neurotologic examination, audiogram and electronystagmogram. An electroencephalogram is frequently a valuable diagnostic adjunct. Further testing should be decided on the basis of the patient's history, examination and prior results. The records of children admitted to Boston City Hospital over a one-year period were reviewed. Of 2,088 pediatric patients, 238 had discharge diagnoses pertinent to the balance mechanism. Of these, 14 had a presenting symptom of dizziness. These cases are analyzed.

Repair of nasal fistula secondary to radiation therapy for Eales's disease

Eales's disease is characterized by neovascularization and idiopathic retinal and vitreous hemorrhages. Therapy in the past included the use of radiation. A case is reported of a patient who received a dose of 15,000 roentgens (approximately 14,250 rad) to the right eye via temporal and nasal portals. He subsequently lost vision in that eye. Thirty years after the radiation was administered, a nasocutaneous fistula developed, and it was closed with a forehead island flap.

Simultaneous carcinomas of the esophagus and upper aerodigestive tract

A review of 150 consecutive head and neck cancer patients over a 22-month period revealed a multiple primary cancer rate of 19%, 9% in the head and neck region. Nine patients (6%) had simultaneous esophageal and head and neck cancers. Complete systematic esophagoscopic examinations, in addition to barium swallow radiographic studies, are recommended for all patients with head and neck cancers.

Anticonvulsant-induced lymphoma

Patients with cervical adenopathy of obscure etiology may present a diagnostic problem to the otolaryngologist. The hydantoin family of anticonvulsants is a rare cause of adenopathy that may range from histologically simple lymphoid hyperplasia to true lymphoma. Between these two extremes is a benign clinical entity with the histologic characteristics of lymphoma. A patient on diphenylhydantoin (Dilantin) therapy developed bilateral true vocal cord paralysis and cervical adenopathy. On pathological examination the lesion was interpreted first as malignant lymphoma and later as hydantoin-induced pseudolymphoma. He has now been followed for over two years. Hydantoin-induced adenopathy may vary clinically from a benign condition to a true lymphoma. The malignant form may present long after the anticonvulsant treatment is discontinued. A 10-fold increase in the expected incidence of malignant lymphoma in epileptic patients on hydantoin therapy has been reported; therefore, these patients required long-term follow-up. The otolaryngologist should be aware of this rare clinical entity as an unusual cause of cervical adenopathy associated with vocal cord paralysis.

The anterior commissure in glottic carcinoma

The laryngeal anterior commissure is a specific anatomic area of the glottis which is often involved by cancer. Of 586 patients with glottic cancer, five (1 percent) had pure anterior commissure lesions and 175 (25 percent) had vocal cord tumors secondarily involving the anterior commissure. One of three of these anterior commissure tumors also had subglottic extension. Despite the presence of blood vessels and lymphatics in the anterior commissure, metastasis to regional lymph nodes in rare (8 percent). Patients with Stage 1 and 2 lesions were treated by hemilaryngectomy with satisfactory results (45/61 -- 74 percent). Only three patients had local recurrence after hemilaryngectomy. Patients with bilateral cord-anterior commissure lesions had the poorest survival and highest recurrence rate, even after total laryngectomy. Subglottic extension of these anterior commissure tumors did not correlate with survival. Survival and recurrence rates were conversely proportional to the stage of the tumor at presentation. Although the anterior commissure is a theoretical site for cancer breakthrough and lymphatic spread, its apparent significance lies in the fact that its involvement by glottic primaries represents only increasing tumor size and thus an advanced stage of disease.

Carcinoma of the subglottic area

The subglottic area is defined as an anatomic region which is cylindrical in shape whose inferior margin is the inferior border of the cricoid cartilage and which is limited superiorly by an imaginary circle 5 mm below the free margin of the true vocal cords. Of 591 patients with glottic and subglottic cancers, only five (percent) had primary subglottic tumors and 132 (22 percent) had glottic tumors with subglottic extension. Sixty-five percent of the patients with glottic primary with subglottic extension were Stage 2 and 35 percent were Stage 3. Most patients were treated surgically. Hemilaryngectomy is a very satisfactory primary modality in the treatment of Stage 2 and some Stage 3 glottic lesions with subglottic extension. Stage 2 and 3 glottic cancers which involve greater than 10 mm of the subglottis carry a significantly decreased prognosis. Patients with T3 lesions with cord fixation with subglottic extension show a decreased survival.

Acalculous parotid sialadenopathy

Acalculous inflammation of the parotid gland has been regarded by some as a specific disorder that can be staged as to the severity of the disease process. A review of the literature, however, indicates a divergence of opinion. It is the purpose of this study to test this hypothesis by a retrospective double-blind analysis of clinical, sialographic and histopathologic findings. Forty-two patients who were seen by the Department of Otolaryngology, Washington University School of Medicine from 1961 to 1970 were evaluated by two separate teams. There were 20 sialograms and 30 pathologic specimens, and all were re-examined. Eleven patients had both sialographic studies and histopathologic examination. The clinical presentations and sialographic findings were reviewed. These findings were then compared to each other. Our results indicate that we could not evaluate the severity of the clinical disease by sialography or histopathology. There was no consistent method of staging the sialographic and pathologic findings. In addition, there was no correlation between these two parameters. They reflect neither the patient's clinical syndrome pattern nor the extent of disease. It appears that the parotid gland responds variable to inflammation. These observations are exemplified by case histories.

Cervical metastasis from an unknown primary

Summary--Forty-nine patients with cervical metastases from unknown primaries were treated during an 11-year period. Thirty-one (63%) of these patients were treated for cure rather than palliation. The three-year survival rate of these patients treated for cure was 39%. Although the treatment of these patients varied, a systematic mode of therapy has evolved: patients with histopathologic diagnosis of epidermoid carcinoma, or undifferentiated malignant tumor, metastatic to the neck from an unknown primary, are treated with full course radiation therapy (6000-7000 rads at 1000 rads per week). This is delivered to the nasopharynx, pyriform fossae, base of tongue, and the neck, and is followed by radical neck dissection in those patients in whom the neck nodes remain palpable. Six of the last 11 consecutive patients treated in this manner are long-term survivors. This paper describes the evaluation of patients with cervical metastases from unknown primaries as well as their therapy.