Fertility preservation in pregnant cancer patients after first-trimester abortion: a new challenge with possible solutions

Fertility preservation in pregnant women recently diagnosed with cancer can be a challenge. Raised levels of human chorionic gonadotropin (Beta-hCG) and progesterone in this population of patients may pose a problem for the prompt initiation of controlled ovarian stimulation (COS) due to a potential negative feedback of these hormones on folliculogenesis; however, it is not feasible to wait for negativization of serum beta-hCG levels before starting controlled ovarian stimulation. In literature, very few cases have been reported regarding the preservation of fertility in pregnant women recently diagnosed with cancer. We performed an extended revision of the literature to evaluate the current knowledge of the management of fertility preservation in women with cancer and we examined two cases closely. The first case study involved a cancer patient who underwent surgical abortion at 6.5 weeks of gestation followed by administration of mifepristone to detach any minimal residual trophoblast and consequently to decrease serum beta-hCG and progesterone levels before starting COS. In the second case study, the cancer patient underwent surgical abortion at 7.1 weeks of gestation and simultaneous unilateral oophorectomy for ovarian tissue cryopreservation due to a limited time for COS. By analyzing the results of these studies, it could be hypothesized that mifepristone administration may favor the decrease of serum beta-hCG and progesterone levels in order to permit rapid initiation of COS. In cases where COS is not feasible, ovarian tissue cryopreservation should be considered as an alternative fertility preservation technique.

Audit of the consultation process on general internal medicine services

OBJECTIVE

To determine the proportion of consultations requested by general internal medicine services that communicate key components of the consultation process to medical subspecialists.

DESIGN

Retrospective chart review by two researchers, using a standardised chart abstraction instrument (93.1% agreement, kappa 0.85).

SETTING

Calgary, Alberta, Canada.

SAMPLE

A random sample of medical consultations was selected from those generated on two medical teaching units (MTUs) from 2003 to 2004.

MEASUREMENTS

The primary measure of interest was whether a "clear clinical question" was posed to the subspecialist, a binary variable.

RESULTS

Two hundred consultations were sampled from the 2885 subspecialty consultations. Of the selected consultations, 94.0% (188/200) were available for review. A clear clinical question was posed in 69.7% (131/188) of consultations (CI 0.63 to 0.74). In a secondary analysis involving a larger sample permitting comparison across subspecialties, 95.1% (368/387) of the consultations, representative of the subspecialties, were available for review. An MTU member contacted the subspecialist for 74.2% of consultations. If a consultation was urgent, a member of the MTU contacted the subspecialist in 81.0% of consultations. Of these urgent consultations, 63.3% had a clear clinical question.

CONCLUSION

More than one in four consultations does not contain a clear clinical question, illustrating suboptimal communication between physicians. Innovative strategies that provide a sustainable solution for overcoming barriers to communication could have a significant impact on quality of care.

A primary germ cell tumor of the anterior mediastinum: a case report and discussion

The anterior mediastinum is the most common extragonadal location for germ cell tumors and accounts for about 50% to 70% of such neoplasms. Embryonal cell carcinomas are one of the rarest forms and account for less than 2%. We present the case of a 19-year-old, white male who was found to have a primary embryonal cell carcinoma of the anterior mediastinum. This case illustrates the subtle complaints that these patients present with, some of the problems and decisions that go into making the diagnosis, and the response to the appropriate therapy. The following discussion takes a look at the variety of germ cell tumors, the vast differential of an anterior mediastinal mass, the workup of such a mass, and the various treatments and outcomes of extragonadal germ cell tumors.

Domestic swine model for the assessment of chemical warfare agent-anesthetic interactions: some effects of sulfur mustard

A domestic swine model was developed to examine the interaction of chemical warfare agents with anesthetics and other drugs used during general anesthesia. Animals were fully instrumented, and clinically relevant physiological parameters were monitored throughout the experimental procedures. Exposure of animals under halothane anesthesia to the chemical warfare agent sulfur mustard (HD; 1 mg/kg intravenous) produced mild signs of systemic intoxication during the subsequent 5 hours. Induction doses of ketamine 1 hour after HD exposure resulted in periods of profound apnea, with continued respiratory distress for the next 2 hours. When animals were treated with HD 1 hour after the initiation of ketamine anesthesia, severe and persistent convulsion-like muscular activity was observed within 45 minutes of HD administration. This nonpurposeful activity was not ameliorated by diazepam but was dramatically reduced or eliminated by resumption of halothane anesthesia. Treatment of HD-intoxicated pigs with succinylcholine produced a prolonged apnea resulting in death. In these apparently mildly HD-intoxicated animals, the introduction of ketamine or succinylcholine can rapidly induce potentially life-threatening situations.

Evidence of declining STD prevalence in a South African mining community following a core-group intervention

OBJECTIVES

To reduce the prevalence of curable sexually transmitted diseases (STDs) in a South African mining community through provision of STD treatment services, including periodic presumptive treatment and prevention education to a core group of high-risk women living in areas around the mines.

METHODS

Women at high risk for STDs attended a mobile clinic monthly for examination and counseling, and were treated presumptively for bacterial STDs with a directly observed 1-g dose of azithromycin. Gonococcal and chlamydial infection rates were measured by urine ligase chain reaction, and genital ulcers were assessed by clinical examination. Changes in STD prevalence among local miners were assessed through comparison of prevalence in two cross-sectional samples of miners taken 9 months apart, and through routine disease surveillance at mine health facilities.

RESULTS

During the first 9 months of the intervention, 407 women used the services. Baseline prevalence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in women was 24.9%; 9.7% of these women had clinical evidence of genital ulcer disease (GUD). The proportion of women with incident gonococcal or chlamydial infections at the first monthly return visit (69% follow-up rate) was 12.3%, and genital ulcers were found in 4.4% of these women. In the miner population, the prevalence of N gonorrhoeae and/or C trachomatis was 10.9% at baseline and 6.2% at the 9-month follow-up examination (P<0.001). The prevalence of GUD by clinical examination was 5.8% at baseline and 1.3% at follow-up examination (P< 0.001). Rates of symptomatic STDs seen at mine health facilities decreased among miners in the intervention area compared with miners living farther from the site and with less exposure to the project.

DISCUSSION

Provision of STD treatment services to a core group of high-risk women may significantly reduce their burden of disease, and may contribute to a reduction in community STD prevalence. In the absence of sensitive and affordable screening tests for STDs in women, periodic presumptive treatment coupled with prevention education is a feasible approach to providing STD services in this population.

Aerosol delivery of liposome-encapsulated ciprofloxacin: aerosol characterization and efficacy against Francisella tularensis infection in mice

The aerosol delivery of liposome-encapsulated ciprofloxacin by using 12 commercially available jet nebulizers was evaluated in this study. Aerosol particles containing liposome-encapsulated ciprofloxacin generated by the nebulizers were analyzed with a laser aerodynamic particle sizer. Mean mass aerodynamic diameters (MMADs) and geometric standard deviations (GSDs) were determined, and the drug contents of the sampling filters from each run onto which aerosolized liposome-encapsulated ciprofloxacin had been deposited were analyzed spectrophotometrically. The aerosol particles of liposome-encapsulated ciprofloxacin generated by these nebulizers ranged from 1.94 to 3.5 microm, with GSDs ranging from 1.51 to 1.84 microm. The drug contents of the sampling filters exposed for 1 min to aerosolized liposome-encapsulated ciprofloxacin range from 12.7 to 40.5 microg/ml (0.06 to 0.2 mg/filter). By using the nebulizer selected on the basis of most desirable MMADs, particle counts, and drug deposition, aerosolized liposome-encapsulated ciprofloxacin was used for the treatment of mice infected with 10 times the 50% lethal dose of Francisella tularensis. All mice treated with aerosolized liposome-encapsulated ciprofloxacin survived the infection, while all ciprofloxacin-treated or untreated control mice succumbed to the infection (P < 0.001). These results suggest that aerosol delivery of liposome-encapsulated ciprofloxacin to the lower respiratory tract is feasible and that it may provide an effective therapy for the treatment of respiratory tract infections.

Answering clinical questions

BACKGROUND

Physicians often have unanswered clinical questions. The purpose of this study was to determine how often the answers to these questions can be found in the medical literature.

METHODS

We collected unanswered clinical questions from family physicians at the end of clinical half-days. The authors and medical librarians then used textbooks and MEDLINE to find answers to each question. We returned to the physicians one to five selected references for each question. Each physician rated these sources on how well they answered the questions and how they might influence the physician's practice.

RESULTS

One hundred three questions were gathered. Physicians asked an average of 0.5 questions per half-day. We searched for answers to 86 questions, and the physicians returned ratings for 84. Forty-five (54%) of these questions were fully or nearly fully answered by the materials returned to the physicians. Of the questions for which answers were found, MEDLINE searches accounted for 71%; textbooks, 20%; and a combination, 9%. MEDLINE searches took an average of 27 minutes, whereas textbook searches averaged 6 minutes.

CONCLUSIONS

The medical literature can provide answers to a majority of clinical questions; however, finding these answers is time-consuming and expensive. Physicians need more efficient ways to answer their clinical questions.

Group remotivation therapy for the 90s

The authors assert that some of the most regressed, treatment-resistant clients with persistent mental illness will show a favorable response to a group approach called remotivation therapy. The remotivation therapy techniques of the 1950s have been updated by psychiatric nurses and a social work clinician in one VA setting. The authors assert that remotivation therapy approaches are easy to implement, personally rewarding, and effective in promoting interaction in such clients.

Interactive effects of insulin, IGF-I and GMl ganglioside on growth of PC12 cells

PC12 cells grow in serum-free medium (SFM) if high doses of insulin (5-50 μg/ml), or combined insulin (5 μg/ml) and insulin-like growth factor-I (3 ng/ml) are added daily. Ganglioside GMl counteracts these effects in a dose-responsive fashion between 10 nM and 50 μM. This provides a serum-free system to study the interactive effects of gangliosides on growth and neuritogenesis in PC12 cells.

Mutant enzymes and tRNAs as probes of the glutaminyl-tRNA synthetase: tRNA(Gln) interaction

This paper focuses on several aspects of the specificity of mutants of Escherichia coli glutaminyl-tRNA synthetase (GlnRS) and tRNA(Gln). Temperature-sensitive mutants located in glnS, the gene for GlnRS, have been described previously. The mutations responsible for the temperature-sensitive phenotype were analyzed, and pseudorevertants of these mutants isolated and characterized. The nature of these mutations is discussed in terms of their location in the three-dimensional structure of the tRNA(Gln).GlnRS complex. In order to characterize the specificity of the aminoacylation reaction, mutant tRNA(Gln) species were synthesized with either a 2'-deoxy AMP or 3'-deoxy AMP as their 3'-terminal nucleotide. Subsequent assays for aminoacylation and ATP/PPi exchange activity established the esterification of glutamine to the 2'-hydroxyl of the terminal adenosine; there is no glutaminylation of the 3'-OH group. This correlates with the classification of GlnRS as a class I aminoacyl-tRNA synthetase. Mutations in tRNA(Gln) are discussed which affect the recognition of GlnRS and the current concept of glutamine identity in E coli is reviewed.

Squamous cell carcinoma and lingual thyroid

This report represents the first known case of squamous cell carcinoma associated with lingual thyroid tissue. Clinical examination of an exophytic mass at the base of tongue, CT imaging and a preoperative biopsy established a diagnosis of squamous cell carcinoma of the midline base of tongue. The therapeutic options and management of this carcinoma by surgical resection, irradiation or combined modalities were analyzed. The surgical option was chosen. This was accomplished via a midline labiomandibulo glossal split and primary repair of the wound. The final pathology report revealed a squamous cell carcinoma of the mucosa of the base of tongue directly over a benign lingual thyroid mass. Post-operative thyroid function studies were consistent with hypothyroidism and a thyroid scan confirmed the absence of thyroid tissue.

Is melanoma changing?

Nine hundred ninety-five cases of melanoma of the head and neck were divided into two groups so that certain comparisons could be made concerning the behavior of melanoma over a 55-year period. One hundred twelve melanomas of the ocular system were excluded from this review. The first group consisted of 660 melanomas seen during a period from 1932 to 1972. The second group consisted of 223 melanomas seen during a period from 1973 to 1987. Thirteen parameters, including sex, age, distribution, pre-existing mole, amelanotic melanoma, delay in diagnosis, classification, levels, local recurrence, regional metastasis, systemic metastasis, morbidity, and survival, were studied to assess the behavior and the variations. There is no question that the most important aspect of the favorable changes that have occurred are because of earlier diagnosis and better management by a larger group of well-trained specialists. There are some subtler changes that could possibly indicate biologic alterations, but this requires more time and study to substantiate.

Sternocleidomastoid muscle transfer and superficial musculoaponeurotic system plication in the prevention of Frey's syndrome

Parotidectomy may be associated with a significant depression in the retromandibular region and a significant incidence of gustatory sweating (Frey's syndrome). Superiorly and inferiorly based sternocleidomastoid flaps and posterior plication of the superficial musculoaponeurotic system were evaluated for their ability to ameliorate both consequences. Sixteen patients with sternocleidomastoid flaps and 16 patients with superficial musculoaponeurotic system plication were compared to a control group of 104 patients. The incidence of Frey's syndrome was 47.1% in the control group, 12.5% (P = 0.025) in the sternocleidomastoid flap group, and 0% (P = 0.005) in the superficial musculoaponeurotic system plication group. The surgical techniques are described. The prevalence of Frey's syndrome is discussed with respect to age, sex, radiation therapy, and the type of parotidectomy performed. The indications and contraindications of the three surgical techniques are described.

The melanocyte and melanoma

This paper reviewed some of the interesting biological aspects of melanocytes and their relationship to the nevus and to melanoma. It also proposed a rationale for "adequate" surgery in the management of melanoma according to level, depth, margins, and trends in treatment. These propositions were derived from an analysis of 995 cases of melanoma of the head and neck.

Simultaneous 'dual system' rehabilitation in the treatment of facial paralysis

Simultaneous dual system rehabilitation of facial paralysis involves using two independent reanimation techniques to optimize facial movement in both a quantitative and qualitative manner. These techniques involve the use of nerve grafting or crossover procedures combined with a dynamic muscle transfer. A group of 37 patients who underwent five different combinations of reanimation was analyzed. The techniques were evaluated using a standard rating scheme for judging success of reanimation procedures. The combination of a masseter muscle transfer to the lower region of the face and a cable graft of the upper facial nerve division appeared to offer excellent results in terms of independent motion of the upper and lower regions of the face and good eye closure, while allowing spontaneous mimetic function in 50% of cases. The advantages and disadvantages of the other techniques are described. The clinical situations in which these techniques have advantage over single reanimation techniques are outlined.

Craniofacial resection of ossifying fibromas and osteomas of the sinuses

Massive fibro-osseous lesions of the frontal and ethmoidal sinuses are rare. If left untreated, these lesions can produce chronic infection, orbital complications, and/or intracranial events. In the past, resection of these lesions has usually been subtotal and a risk of damage to intracranial structures existed, particularly to the dura, due to poor exposure, and a high recurrence rate was also present. We have treated eight such lesions with a combined craniofacial approach for total resection with resolution of symptoms, without recurrence, and without occurrence of cerebrospinal fluid leak, damage to the orbital contents or intracranial structures, or resultant cosmetic deformity.

Purification and characterization of the adenine phosphoribosyltransferase and hypoxanthine-guanine phosphoribosyltransferase activities from Leishmania donovani

The adenine phosphoribosyltransferase (APRTase) and hypoxanthine-guanine phosphoribosyltransferase (HGPRTase) activities from promastigotes of Leishmania donovani have been purified to homogeneity using ammonium sulfate precipitation, DEAE-cellulose exclusion, and either AMP-agarose (APRTase) or GTP-agarose (HGPRTase) affinity chromatography. The specific activities of the affinity-purified APRTase and HGPRTase fractions were 326-fold and 1341-fold greater than those in the 40-80% ammonium sulfate precipitate, respectively. The purified APRTase migrated as a single band on sodium dodecyl sulfate (SDS) polyacrylamide gels with a size of 29 kDa, while HGPRTase was also determined to be homogeneous by SDS gel electrophoresis with a size of 24 kDa. In addition, a mutant cell line, APPB2, partially deficient in APRTase activity, still contained quantities of purifiable APRTase protein, while a clonal secondary derivative of the APPB2 cell line that is completely deficient in APRTase activity, APPB2-640A3, failed to express purifiable APRTase protein. The homogeneous enzymes possessed apparent Km values for their nucleobase substrates between 2.0 and 5.0 microM, and both enzymes were inhibited by their immediate or ultimate reaction endproducts, APRTase by AMP and PPi and HGPRTase by GMP, GTP, and PPi. The generation of homogeneous preparations of APRTase and HGPRTase protein will serve as a prerequisite for the generation of immunological and molecular biological probes to analyze the leishmanial phosphoribosyltransferases.

Surgery on the buccal fat pad in masseter transfer

The buccal fat pad is an essential anatomic structure in the esthetic presentation of the face. It may become hypertrophied, with fullness of the cheek, or atrophic, with a sunken appearance, or become a plus or minus factor in reconstruction in this area. Lipoma of this pad is extremely rare, but it must also be differentiated. There are, therefore, certain circumstances where the presence or absence of the buccal fat pad can create a specific imbalance and asymmetry in the face. The correction of these conditions may require reduction or augmentation. The anatomy, the risks, the classification, and the various surgical techniques that are available to accomplish this are outlined and correlated to the masseter muscle transfer.

Primary neoplasms of the facial nerve

A series of 30 primary facial nerve tumors is reviewed. Most of them were benign (n = 26); there were four malignant tumors. Neoplasms originating within the temporal bone were found to have preoperative facial paralysis in 84 percent of cases; the extracranial tumors had a 35 percent incidence of preoperative facial paralysis. All tumors in this series were treated surgically--by means of a middle fossa or transmastoid approach for the intratemporal group of tumors; the extracranial tumors were removed by the technique of parotid tumor surgery with complete facial nerve dissection. All the patients with preoperative facial weakness required facial nerve transection. Facial paralysis was rehabilitated with nerve grafts, hypoglossal crossover, or muscle transfers. Because "normal" facial expression is still not attainable following repair of complete facial nerve transection, an early diagnosis, hopefully prior to total neurotmesis, is essential. All patients with unexplained facial weakness, especially that which is progressive and persistent, should have the entire course of the facial nerve investigated for the possibility of treatable etiology.

Pseudotumor of the pterygomaxillary space presenting as anesthesia of the mandibular nerve

Pseudotumor is a term used to describe a space occupying inflammatory lesion which mimics a true neoplastic process in its clinical presentation. In this paper, we report a pseudotumor of the pterygomaxillary space that presented with anesthesia and paralysis of the mandibular nerve. The importance of this case is to call attention to pseudotumors as a clinical entity and to document a case of an extraordinarily aggressive variant that required a surgical approach usually reserved for malignant tumors.

Cheiloplasty in the treatment of facial paralysis

There have been dramatic improvements in the treatment of facial paralysis. These include the successful use of free autogenous nerve grafting, nerve crossover techniques, regional masticatory muscle transposition, and free muscle grafts. The techniques are applied to total, partial, and regional paresis. The bulk of information on rehabilitation of the face has come from clinical empiricism, but basic research in nerve and muscle physiology and attempts at multiple classifications regarding indications and criteria have added to the splendor of this drama. One facet that has not been emphasized is the use of cheiloplasty in long-standing facial paralysis. Long-standing facial paralysis has both a neural and muscular deficit that cannot be rectified by a single concept or operation. It is essential to regionalize the rehabilitation, implant a kinetic muscular potential, supply some static support and elevation, and address the nonfunctional muscles about the paralyzed lips. This latter concept includes lip shortening and lip-flap transposition. A coordinated combination of these techniques has the best opportunity of maximizing the improvement in long-standing facial paralysis associated with severe muscle atrophy.

Pendulosity in regional flaps about the head and neck

Pendulosity rarely occurs in flap transposition in the area of the head and neck. It is related to physical and physiological factors that derive from the volume of tissue transplanted, the neatness of its fit into the wound, its supportive facilities, its functional activity, its relation to gravity, and the effect of its perimeter scar tissue bed and venous drainage system. It is amazing that this condition does not appear more commonly when one considers that as much as 1,000 cc of inert tissue may be transposed as a volumetric mass, either with a singular vascular pedicle or as a singular microvascular anastomosis or a randomized soft tissue pedicle base. The difficulty is almost always compounded by the fact that the tissue does not contain a specific lymph drainage facility. The majority of these physiological handicaps, however, are accommodated by the receptiveness of the tissues of the wound and the venous drainage of the flap. If these should fail, edema and then pendulosity will occur. The condition can be improved by repositioning and a reduction in the size of the flap.

Therapeutic intervention scoring as a measure of performance in a helicopter emergency medical services program

Helicopter emergency medical services (HEMS), which are both expensive and resource intensive, lack objective measures for system evaluation. We computed the Therapeutic Intervention Scoring System (TISS) score for all patients during six consecutive months of service in a HEMS program to assess the value of this score for measuring the performance of the program. The TISS assigns values ranging from 1 to 4 for 57 medical and surgical interventions to measure the intensity of care during a 24-hour period. The TISS was recorded for 203 patients beginning at the time HEMS transport was requested. These flights also were classified as appropriate or inappropriate, given the information available, when HEMS care was initiated and days later when diagnostic evaluation was complete. Classification was done on the basis of whether the following criteria (potentially) ensure patient survival or improve outcome: speed of transport, presence of a medically skilled flight team, or the helicopter's ability to overcome hostile environmental conditions. The mean TISS score for all patients was 21.7. One hundred thirty-two of 203 flights (65%) were thought to be medically necessary, both at the time HEMS was requested and later (mean TISS, 28.1; analysis of variance, P less than .001). Thirty-four flights (17%) were thought to be appropriate using the information available at flight time, but not after the diagnostic workup was completed (mean TISS, 10.0). Thirty-six patients (18%) did not appear to require helicopter transport at any time, and had a mean TISS of 9.0. We conclude that TISS is a useful, objective measure of the performance of a HEMS program, and it should be tested in other HEMS programs.

Genetic parameters and environmental factors associated with type traits scored on an ordered scale during first lactation

Sixty subjective and linearized type data were recorded on 7375 first lactation Holstein cows. Data were analyzed by paternal half-sister analysis for genetic parameters. One hundred and six sires were represented. Two kinds of heritability estimates were obtained; the first was a method 3-derived estimate for the raw scale and the second was a "nonlinear method 3"-derived estimate for an underlying scale. Whenever estimates of heritability on the raw scale were positive, larger estimates were generally obtained on the underlying scale. Some udder traits (e.g., depth, rear length, rear balance, teat placement, rear teat length, rear width) had underlying heritabilities between 10 to 30%. Suspensory strength and teat shape had no genetic variation. Of feet and leg traits only set (.14) and cleanness of hocks (.09) had heritabilities above 6%. Some functional traits (milking speed, edema) had heritabilities near 11%. Disposition, mastitis score, and milk letdown had no genetic variation. Most body traits (e.g., pin and hip width, length and levelness of rump, rib spring) had heritabilities between 15 and 30%. Method 3 phenotypic and genetic correlations relations were computed for the raw scale. Most phenotypic correlations were near zero. Traits associated with size or skeletal dimension had positive phenotypic typic and genetic correlations. Fore udder length, rear udder width, and rear udder height had positive genetic correlations (range .21 to .43). Udder depth had moderate genetic correlations with most udder traits, teat traits and body traits. The statistical models included describer, stage of lactation, and calendar month of description effects. In general, describer effects were the largest and most significant kind of environmental effect. Stage of lactation effects occasionally showed consistent trends. Month effects appeared to be unpredictable.

Treatment and prognosis of mucoepidermoid carcinoma in the pediatric age group

Although mucoepidermoid carcinoma is the most common malignant salivary neoplasm in adults, it occurs rarely in the pediatric age group. A retrospective study of 15 pediatric cases from 1954 to 1984 showed that 13 of the patients were 10 to 15 years old, and 11 were female. The parotid (11/15) and the palate (4/15) were the sites involved. Tumors were graded into three categories: well differentiated (grade I), moderately differentiated (grade II), and poorly differentiated (grade III). Tumor grade influenced the method and outcome of treatment. Wide local composite resection was used for palatal tumors, and total parotidectomy (with or without nerve resection) and nodal dissection was the technique selected for parotid tumors. No nodal or distant metastases were present in the poorly differentiated tumor category (2/15). A follow-up period of ten years or more was possible in 90% of the cases. The prognosis for those studied is excellent, and there have been no deaths attributable to the malignant process.

The risk to the orbit in head and neck cancer

Cancers in the head and neck are recognized as placing their environs at risk. The orbit is threatened by a variety of cancers originating in adjacent structures because of its anatomic relationship to skin, sinuses, nasal cavity, skull, palate, and salivary glands. The poignancy of this is highlighted by the fact that the orbit contains the organ of sight and also has high aesthetic value. An evaluation of the pathologic physiology of the various neoplasms affecting the orbit, their management, the methods of reconstruction, and the criteria for radical and conservation techniques will be discussed.

Intranasal composite grafts for dorsal support

Reconstruction of the dorsal support of the nasal pyramid is often a challenging proposition. Intranasal resection of the septum or lateral walls of the nose will cause collapse, widening, shortening, and a depressed profile. This problem has been treated by cantilever bone grafts, cartilaginous grafts, composite grafts, skin grafts, and struts with some success. The correction of total resection of the nasal septum by the implantation of a biwinged composite cartilage graft acts as a buttress in its augmentation and support of the dorsum of the nose.

The meaning of life-threatening disease in the area of the head and neck

The revelation that one has a life-threatening disease creates a sentient flood of emotions that infuse the patient with fear, confusion and depression. It contains the spectrum of pain, suffering, deterioration of life-style, crippling and possible annihilation. This burden falls first on the patient and his family, and then on his doctor. The drama is a dilemma of cure or palliation wrapped about the emotional core of that person with science, drugs, technology, mysticism and hope. The ongoing process is the most dynamic encounter of being alive, and before it is finished will have used and drained a large percentage of the vulnerable emotions that identify our humanness. An overview of these involvements as they relate to the area of the head and neck shows how complex the process has become, the remoteness of its solution and the truth of its experience.

Reconstruction of half of the face

A 29-year-old man underwent a severe electrical burn involving the entire right side of the face, resulting in destruction of the temple, orbit, a portion of the nose, zygoma, and maxilla, through-and-through destruction of the cheek and lips, and a portion of the parotid gland and buccal mucosa. This massive and debilitating wound was an acute surgical emergency, as far as life-support measures were concerned. Gradually, the patient underwent débridement, and finally resurfacing of the entire right side of the face with a large deltopectoral flap. Over four years, this flap, the area of the orbit, and the area of the lips underwent rehabilitation and the transportation of residual regional muscles, and the debulking and repositioning of the flap was carried out. The orbit was finally rehabilitated with a prosthesis.

Management of the ear canal in head and neck surgery

The management of the ear canal in the treatment of tumors occurring in the area of the head and neck is a highly specialized problem. The material for this report is a derivative of the treatment of tumors involving the auricle, tragus, the skin of the cheek, temple, mastoid, parotid gland, ear canal, and middle ear. The extensive variety of histopathologic conditions and positions of the various tumors creates special problems in preserving and reconstructing the ear canal, saving the tympanic membrane, and rehabilitating the area of the ear canal when these structures have had to be resected. Six basic techniques have been used in rehabilitating this unique area, by using regional skin, free skin grafts, regional flaps, cervical flaps, combinations of these techniques, and large cutaneous and myocutaneous chest and back flaps for the larger ablations.

Metastatic basal cell carcinoma of the head and neck

Five new cases of metastatic basal cell carcinoma are presented to highlight the potential of this tumor to develop malignant metastases. Histologic criteria of the primary and metastatic site are presented along with a review of the pertinent world literature.

Degloving approach for total excision of inverted papilloma

Inverted papilloma, because of its insidious and aggressive clinical course, must be completely excised. Previously, the customary procedure advocated for this goal was a lateral rhinotomy. The degloving approach, which consists of lifting the soft tissues from the mid portion of the face, thereby furnishing unlimited exposure to the pyriform fossae and the lateral nasal walls, offers an excellent alternative to the lateral rhinotomy technique. The degloving procedure involves no external scarring and improves the visibility of the total operative field. En bloc dissection of the lateral nasal wall is then accomplished and extended to include a sphenoethmoidectomy or partial excision of the medial orbital wall, as dictated by the extent of disease. The procedure has been performed by the authors in 46 cases, and has proved to be an extremely valuable technique, displaying excellent cosmetic and functional results with minimal complications.

Functional and aesthetic consequences of total platysma resection

The functional and aesthetic effects of total unilateral platysma resection during ablative surgery is described and outlined for the first time (to our knowledge). The consequences of this resection are analyzed with respect to the partial facial paralysis that is evident. A model describing the dynamics of this paralysis is presented. These data are important in understanding the contribution of the platysma to the smile and the effects of manipulating this muscle during aesthetic and reconstructive neck surgery.

Intralaryngeal release for tracheal anastomosis

An operation for obtaining additional length in order to achieve end-to-end anastomosis of the trachea without significant suture-line tension is described. The intralaryngeal procedure lengthens the larynx approximately 1 to 2 cm without restricting its function. It is an expedient, effective technique when used primarily, or adjunctively, with a suprahyoid or mediastinal release.

Adenoid cystic carcinoma of the subglottic region

Adenoid cystic carcinoma is one of the most common malignancies of the minor salivary glands in the head and neck. However, adenoid cystic carcinoma of the larynx is very rare, with less than 75 cases reported in the literature. We present three cases of adenoid cystic carcinoma of the subglottic region with 6-year, 9-year, and 18-year follow-up, respectively. The literature on adenoid cystic carcinoma of the subglottic area is reviewed. Symptoms of long duration, slow progressive growth with tendency for local recurrence, and eventual development of pulmonary metastasis is common. Five-year survival statistics do not appear as relevant as 10- and 20-year survival rates in this entity because of the often slow but pernicious nature of adenoid cystic carcinoma of the subglottic area. Despite aggressive therapy, the disease often leads to the eventual death of the patient. In our series one patient died, and two patients are alive and free of disease. The evaluation, treatment, and clinical course of this disease is discussed.