Animal bites to the head and neck

There is controversy regarding the timing of repair and the use of prophylactic antibiotics in patients with animal bites to the head and neck. In this paper we review our experience with such wounds, and address surgical management and the use of prophylactic antibiotic therapy. A retrospective review of the medical records of 29 patients with animal bites to the head and neck was conducted. All patients were seen and treated at a large teaching hospital in Houston, Texas over an 18-month period. Seventy-six percent of our patients were 12 years old or younger. Most came to the emergency room soon after sustaining their injuries, and their wounds were repaired primarily with favorable results. There were no cases of wound infection. Ninety percent were treated with prophylactic antibiotics. The wounds of the 10% of patients who did receive antibiotics were similar to those of the other patients and healed well without infection. Wounds resulting from animal bites to the head and neck can be repaired primarily when treated shortly after injury. Further prospective, randomized studies are recommended to evaluate the effectiveness and necessity of prophylactic antibiotic therapy in this patient population.

Sinusitis in the intensive care unit patient

A retrospective study was undertaken to determine the incidence of sinusitis as a source of fever in the intensive care unit (ICU) patient, evaluate the effectiveness of radiologic studies in diagnosing sinusitis, and develop guidelines that may help predict the result of antral lavage. Sixteen of 52 (30.7%) lavages in patients studied with plain films and 27 of 67 (40.3%) lavages in patients studied with computed tomography of the sinuses revealed purulence in the maxillary sinuses. Conversely, 23 of 30 (76.7%) of the cases with purulence in the middle meatus had purulence in the maxillary sinus (chi-squared = 27.1). If no purulence was seen, the results of the antral lavage were negative in 68 of 89 cases (76.4%). When physical examination was used in conjunction with computed tomography, 92.3% of lavages confirmed purulence in the maxillary sinus (chi-squared = 16.6). In conclusion, the most important factor in predicting a positive result with antral lavage is the presence of purulence in the middle meatus on physical examination in conjunction with the presence of sinus disease on computed tomography of the sinuses.

Endoscopic approach to traumatic visual loss

OBJECTIVE

To review our experience with the use of endoscopic optic nerve decompression in traumatic blindness.

METHOD

We did a retrospective analysis of patients with traumatic blindness that underwent endoscopic decompression of the optic canal to determine postoperative visual acuity and correlate it to preoperative visual loss and intraoperative findings. The setting was a Level I university trauma center. We identified 8 patients treated with both surgery and steroids over a 10-month period beginning in 1993 (Seven males, one female).

RESULTS

Four of six patients with total blindness (no light perception) had improvements in visual acuity. In three patients, visual acuity returned to preinjury levels. One patients with total blindness was operated on 6 weeks after injury and had a visual acuity of 20/800 at 1-year follow-up. Two patients with hand motion preoperatively had improvement in visual acuity. In one patient, vision returned to normal (20/20), and in the other it improved to 20/200). Five patients were operated on after megadose steroid treatment for at least 48 hours failed; four of five noted dramatic improvements in visual acuity.

CONCLUSION

The endoscopic approach may be used to successfully decompress the optic nerve in traumatic blindness.

Risk factors associated with hearing loss in neonates

PURPOSE

To identify the risk factors associated with hearing loss in our neonatal patient population and compare them to the ones listed by the Joint Committee on Infant Hearing.

PATIENTS AND METHODS

The medical records of 50 consecutive infants with hearing impairment by auditory brainstem response (ABR) audiometry were reviewed retrospectively and were compared with the records of 50 randomly selected newborns that had normal hearing.

RESULTS

In our review, only five of 18 variables were found to be associated with hearing impairment. These are: hyperbilirubinemia, craniofacial anomalies (CFA), length of stay in the intensive care unit, respiratory distress syndrome, and retrolental fibroplasia. The last three variables are not listed in the high-risk register published by the Joint Committee on Infant Hearing.

CONCLUSION

The results of this study provide for additional risk factors that may be used in infant-hearing screening programs.

Contemporary management of deep neck space infections

Deep neck infections continue to be seen despite the wide use of antibiotics. These infections follow along fascial planes to create deep neck space abscesses. The clinical presentation often points to the space involved. Understanding the regional anatomy gives the surgeon the ability to treat these grave infections. The records of 24 patients with a diagnosis of deep neck space abscess admitted to Hermann Hospital between 1988 and 1993 were reviewed. Fifty percent of the patients had received antibiotics for an infection of the ear, nose, or throat before the development of a neck space abscess. Ten patients had parapharyngeal abscesses, seven had retropharyngeal abscesses, six had submandibular space abscesses, and one had parotid space abscess. Thirty-five organisms were isolated in 18 cases (1.9 isolates per patient). The most common organism cultured was Streptococcus (13 of 18), followed by Staphylococcus (6 of 18), Bacteroides (5 of 18), Micrococcus (2 of 18), and Neisseria (2 of 18). One case each of Candida, Enterobacter, Enterococcus, Peptostreptococcus, Proteus, Proprionobacter, and Pseudomonas was cultured. Six patients had no growth on culture but did have organisms found on Gram's stain. The operative techniques and antibiotics used are discussed. The main complications of jugular vein thrombosis, carotid artery rupture, and mediastinitis are described, as well as an unusual case of meningitis from a large retropharyngeal-parapharyngeal abscess.

Superior mediastinal dissection in the treatment of Hürthle cell carcinoma of the thyroid

BACKGROUND

Hürthle cell carcinoma of the thyroid frequently metastasizes to regional lymph nodes. Delayed lymph node dissection may become necessary, adding little risk to patient survivability; however, metastatic disease to the superior mediastinum that cannot be promptly detected, represents a survival threat that deserves special attention. The purpose of this study is to review our experience in managing Hürthle cell carcinoma of the thyroid and make recommendations for appropriate treatment.

PATIENTS AND METHODS

A retrospective review of 371 thyroid neoplasms seen between 1987 and 1994 yielded six patients with Hürthle cell carcinoma of the thyroid gland. These include three cases treated with thyroidectomy and transcervical superior mediastinal dissection (SMD) as initial treatment and three cases treated with thyroidectomy alone.

RESULTS

Of the three patients treated with SMD as part of their initial treatment, one had occult micrometastases to the superior mediastinum. All three patients remain alive and disease free at least 3 years later, whereas all three patients treated with thyroidectomy alone developed superior mediastinal metastases and died of their disease.

CONCLUSION

We propose that at the time of initial surgery, a transcervical SMD may prevent spread to the superior mediastinum and therefore, improve survivability.

Pediatric gunshot wounds to the head and neck

Gunshot wounds to the head and neck in the pediatric population have become alarmingly common. They often result in death of the victim, devastate families, and inflict a considerable financial burden to hospitals and society. We present a retrospective study of cases treated at a level I trauma center in Houston, Texas, from July 1990 to July 1993. We identified 115 cases of gunshot wounds in children, 32 of which were exclusively confined to the head and neck region. There were 26 male and 6 female patients. Ages ranged from 3 to 17 years. The cranial cavity was involved in 13 cases, leading to 9 deaths and 1 institutionalization. The shootings took place at home in 11 cases, and they involved play in 12 cases. The shooter was known to 14 of the victims, and the wounds were self-inflicted in 7 cases. The most common type of weapon was the .22 caliber pistol, which caused four of the deaths. Two of our cases involved BB air rifles, one of which mandated a craniotomy for the evacuation of an epidural hematoma. Our findings indicate that gunshot wounds to head and neck in children are in most instances preventable and result in high fatality rates because of common intracranial involvement, even when low-energy missiles are used.

Pediatric Gunshot Wounds to the Head and Neck

Gunshot wounds to the head and neck in the pediatric population have become alarmingly common. They often result in death of the victim, devastate families, and inflict a considerable financial burden to hospitals and society. We present a retrospective study of cases treated at a level I trauma center in Houston, Texas, from July 1990 to July 1993. We identified 115 cases of gunshot wounds in children, 32 of which were exclusively confined to the head and neck region. There were 26 male and 6 female patients. Ages ranged from 3 to 17 years. The cranial cavity was involved in 13 cases, leading to 9 deaths and 1 institutionalization. The shootings took place at home in 11 cases, and they involved play in 12 cases. The shooter was known to 11 of the victims, and the wounds were self-inflicted in 7 cases. The most common type of weapon was the .22 caliber pistol, which caused four of the deaths. Two of our cases involved BB air rifles, one of which mandated a craniotomy for the evacuation of an epidural hematoma. Our findings indicate that gunshot wounds to head and neck in children are in most instances preventable and result in high fatality rates because of common intracranial involvement, even when low-energy missiles are used.

Inhibition of Cholesteatoma Migration in vitro with all-Trans Retinoic Acid

Retinoids have recently become of interest to clinicians because of their ability to inhibit migration and proliferation of premalignant squamous cells while enhancing growth and proliferation of normal cells. An in vitro investigation was undertaken to determine whether retinoic acid exhibits similar inhibitory effects on cholesteatoma cells. Cholesteatoma specimens were obtained intraoperatively from 10 patients undergoing mastoidectomy or revision mastoidectomy for chronic ear disease. Cholesteatoma explant growth and en mass migration were observed daily, and topographic maps were constructed at various time intervals to quantify rate and direction of expiant migration in the presence or absence of all- trans retinoic acid. Before all- trans retinoic acid administration, explants migrated very rapidly (1 to 2 mm/day). A maximum threefold inhibition of migratory rate occurred, with explants exposed to 0.1 μmol/L retinoic acid when compared with controls. A sixfold maximum inhibition was observed at higher retinoic acid concentrations (5 μmol/L). On removal of all- trans retinoic acid, twofold and fourfold increases in migratory rates were observed. The direction of explant migration varied significantly for long periods of time and appeared not to be affected by retinoic acid. This investigation suggests that all- trans retinoic acid has an inhibitory effect on cholesteatoma cell migration. Retinoids may have a role in controlling cholesteatoma disease in the future.

Paraneoplastic syndromes in patients with head and neck cancer

Paraneoplastic syndromes are distinct physiological disorders of malignancy that occur remote from a tumor site. A review of a number of paraneoplastic syndromes occurring in patients with head and neck cancer has been discussed. These syndromes can produce life-threatening sequelae in the patient with cancer. Understanding these syndromes may provide important clinical information to assist in the early detection of occult malignancy and in reducing the occurrence of tumor-associated morbidity.

Teratomas of the head and neck

Teratomas of the head and neck are uncommon. They are composed of tissues from all three germ layers with varying degrees of differentiation. They arise from pluripotent stem cells and ectopic embryonic nongerm cells. Head and neck teratomas most commonly emerge during the neonatal period and are associated with airway obstruction and high rates of mortality in untreated patients. The tumors are usually benign, but when found during adulthood, they have a high incidence of malignancy. The most common site of occurrence is the cervical region and the nasopharynx. We presented a rare case of teratoma originating from the base of the tongue. This case is an example of the development of teratoma by pinching off of remnants of the three germinal areas, which become marginated in the normal migratory pathway as the different structures of the head and neck develop. The remnants developed into the predetermined organ systems, giving rise to the heterotopic tissues encountered. The recommended treatment for head and neck teratomas is surgical excision. When a patient is experiencing respiratory difficulty, establishment of an airway is a priority.

Gunshot wounds to the head and neck

Gunshot wounds to the head and neck contribute to substantial medical, economic, and social problems in the United States today. The treatment of these patients requires the contemporary head and neck surgeon to be precisely informed in anatomy, wound ballistics, resuscitation, and surgical decision making. Ninety recent cases at the University of Texas Health Science Center affiliated hospitals in Houston were reviewed and are reported. Data show substantial trends in patient demographics and corroborate other reports in the trauma literature. Controversies in patient management continue, but current evidence favors a protocol of selective surgical exploration.

Massive epistaxis due to pseudoaneurysm. Treated with detachable balloons

A case of massive epistaxis refractory to nasal packing and bilateral surgical ligation of the internal maxillary and ethmoidal arteries is presented. Angiography revealed a pseudoaneurysm of the cervical portion of the internal carotid artery, and intravascular detachable balloons were used for epistaxis control. The appropriate use of intravascular diagnostic and therapeutic techniques is described.

The relationship between the nasal cycle and mucociliary clearance

Nasal airway resistances were measured bilaterally on subjects at 30-minute intervals over 6 hours using anterior rhinomanometry. The first 10 subjects found to exhibit alternating congestion and decongestion of the nasal mucosa (i.e., the nasal cycle) were included in the study. Using the saccharin method, nasal mucociliary clearance was determined for each subject in both the congested and decongested phases of the cycle. The results were statistically significant at the P less than .09 level, highly suggestive of a difference in nasal mucociliary clearance between the two phases of the cycle, with the congested phase having the more rapid clearance. However, when compared to the mucociliary clearance times in disease states, the difference in transport times between the two phases is probably not clinically significant.

Spontaneous cervical and mediastinal emphysema

Subcutaneous cervical emphysema often appears as a result of surgery or trauma. However, when it occurs spontaneously, the patient may present with clinically impressive and dramatic features. The etiology is related to the rupture of terminal alveoli and dissection of air along the pulmonary vasculature. Exercise may contribute to the process by increases in intrathoracic pressure. Six cases of spontaneous cervical emphysema, all related to SCUBA diving training at a Naval facility, were recently seen at our institution. Proper management entails having a high index of suspicion for diagnosis, and then being able to identify potentially life-threatening complications.

Surgical anatomy of the lateral nasal wall

Both the success and safety of intranasal functional endoscopic sinus surgery depend on the surgeon's knowledge of nasal and sinus anatomy, especially the lateral nasal wall. The purpose of this study was to determine measurements and angles between lateral nasal wall landmarks. Linear and angular measurements were made to determine the mean and range distances between selected structures. The results provide a guide for the surgeon.

Interobserver variability in the interpretation of fine-needle aspiration biopsy of head and neck masses

Fine-needle aspiration biopsy is gaining acceptance as a clinically useful tool. We set out to evaluate the accuracy of fine-needle aspiration biopsy at our institution by measuring the interobserver variability in cytopathologic interpretation, and by measuring the agreement between cytopathologic and histologic diagnosis. In a prospective study, 253 aspirations were performed on head and neck masses by the otolaryngology service. Specimens were interpreted independently by two cytopathologists (V.J.S. and P.Z.), and interpretations were compared with the surgical histopathologic diagnosis when available. The interobserver variability between cytopathologists was 8% with a specificity of 96% and a sensitivity of 97%. We conclude that fine-needle aspiration biopsy is a safe and useful tool in the diagnosis of head and neck masses. In the diagnosis of epithelial cysts and squamous epithelial malignancies, fine-needle aspiration biopsy is as accurate as open biopsy.

Vitamins A and E do protect against oral carcinoma

Tumorigenesis requires accelerated polyamine biosynthesis, and elevated levels of ornithine decarboxylase, the rate-limiting enzyme in this reaction chain. The primary goal of this study was to determine whether induction of oral cavity carcinoma by dimethylbenzanthracene was accompanied by increased ornithine decarboxylase. It has previously been demonstrated in an oral carcinogenesis model that cotreatment with vitamins A or E delayed tumor development. The second goal of this study was to determine whether this chemoprotective effect was associated with a decrease in ornithine decarboxylase activity. We found that dimethylbenzanthracene did stimulate ornithine decarboxylase. Vitamins A and E alone also stimulate ornithine decarboxylase, and this effect is additive with dimethylbenzanthracene. Use of both vitamins together prevents the additive effect of either, alone, and vitamin A inhibits the late-phase ornithine decarboxylase response to dimethylbenzanthracene in all animals. We conclude that pretreatment with vitamins A, or A and E together protects against the carcinogenic action of dimethylbenzanthracene, and that the mechanism of this protection is early truncation of the ornithine decarboxylase response to dimethylbenzanthracene.

The effect of hyperbaric oxygen therapy of oral mucosal carcinoma

Hyperbaric oxygen is sometimes used in the course of treatment in head and neck cancer patient. This study was undertaken to investigate the effect of hyperbaric oxygen on oral cavity carcinogenesis in an animal model. Dimethylbenzanthracene was applied three times weekly to induce oral squamous cell cancers. The group that received simultaneous hyperbaric oxygen had fewer tumors, but the tumors were larger than the dimethylbenzanthracene-only group. We concluded that hyperbaric oxygen has a tumor-suppressive effect during the induction phase of oral carcinoma and appears to have a stimulatory effect during the proliferative phase of carcinoma in this animal model.

Teaching indirect mirror laryngoscopy

Indirect mirror laryngoscopy is difficult to learn. An anatomic model of the oropharynx and larynx is described here. This model is used to familiarize medical students with the component skills of mirror laryngoscopy. The students progress to competency at mirror laryngoscopy on patients more quickly after initial use of this model.

Laryngeal cancer without spread to the neck: treatment options and outcome

We examined treatment and outcome variables in patients who had laryngeal cancer without clinical evidence of spread to the neck. In our patient population, there was a 24% overall recurrence rate for N0 laryngeal cancer. Initial manifestations, including stage and location of tumor, did not influence recurrence (P greater than .1). Initial treatment of the primary T3 or T4 tumor with radiotherapy alone was positively correlated with recurrence (P less than .0 for T3, P less than .0 for T4), but initial treatment of the neck did not appear to affect chance of regional or distant recurrence (P greater than .1). Approximately half of the patients who had recurrent disease were salvaged. Neither chance of salvage nor final disease-free status was significantly associated with any of the variables (P greater than .1).

Osteomyelitis of the mandible

The presenting characteristics and clinical courses of 60 patients with mandibular bone infections are described. Fifteen of the patients had posttraumatic osteomyelitis, 13 had odontogenic osteomyelitis, and 28 had osteoradionecrosis. Most infections (93%) were polymicrobial, and anaerobes played an important role. Types of surgical procedures and use of adjunctive hyperbaric oxygen are described. There were minimal differences in presentation or response to treatment between these four different groups. A clinical staging system for mandibular bone infections is proposed and results of treatment are retrospectively analyzed by stage. The results support the concept that initial treatment planning can be safely and successfully based on the stage of the disease.

Magnet extraction of frontal sinus foreign body

We report a metallic foreign body that entered through the anterior table of the frontal sinus, and rolled down to lodge in the nasofrontal duct. An electromagnet was used to remove the foreign body through a trephination.

Surgical care of submental gunshot wounds

The care of patients with self-inflicted facial gunshot wounds is complex and challenging. The magnitude and self-inflicted nature of the injuries naturally give rise to questions about potential for successful rehabilitation. The surgical care and rehabilitation of ten such patients are described. The initial grotesque disfiguration belies the reasonable chances for functional restoration. Patients in this series who completed reconstruction swallow well enough to maintain body weight, speak understandably, breathe without tracheostomy, and have an appearance sufficiently normal that they can interact socially without embarrassment. Guidelines are proposed for multidisciplinary medical care leading to satisfactory functional, aesthetic, social, and psychiatric rehabilitation.

Bacteriology of middle ear effusions

We studied fluid obtained from middle ear effusions (MEEs) during 908 myringotomy and tube insertion procedures on 495 children aged 4 months to 12 years. Under general anesthesia the external auditory canal was sterilized with povidone-iodine (Betadine) and alcohol, and myringotomy was done. Fluid was aspirated into a Luki tube and sent for culture and sensitivity determination. The median age of patients was 3 years 5 months; 1-year-old children comprised the largest single group. Two thirds of the children were male. Effusion was present in three fourths of the ears; in about 20% of these, culture grew bacteria. Haemophilus influenzae made up almost 50% of the pathogens, with the percentage decreasing with age. Almost 90% of the H influenzae organisms were sensitive to erythromycin, and about three fourths to ampicillin and cephalosporin.

Esthesioneuroblastoma metastatic to the trachea

Esthesioneuroblastoma is an uncommon nasal neoplasm of neural crest origin, which is recognized for its propensity for local recurrence and distant dissemination by both lymphatic and hematogenous routes. Hematogenous spread occurs most frequently to the lungs and bones, but metastases to the liver, spleen, scalp, face, breast, adrenal, aorta, and ovary have been reported. We present a patient who developed metastatic esthesioneuroblastoma of the trachea 1 year after successful craniofacial resection of his primary tumor. The patient was treated by YAG laser resection of the metastatic tumor followed by radiotherapy. He was free of tracheal disease 1 year after treatment of the metastases.

Endotracheal tube safety during laser surgery

The most morbid complication of laryngeal laser surgery is an endotracheal tube fire. The purposes of this study were to determine the efficiency of saline solution-soaked cottonoid pledgets in protecting endotracheal tube cuffs from the laser beam and to evaluate the safety of four commonly used endotracheal tubes. The method involved measurement of perforation times of saline-soaked cottonoid pledgets with controlled variables of air exposure times and laser energy. The second part evaluated the safety and ignition properties of the red rubber, silicone, polyvinyl chloride, and Xomed Laser-Shield tubes by studying their perforation times and ignition properties under controlled oxygen concentrations. The results revealed that saline-soaked pledgets are very efficient in protecting endotracheal tube cuffs. The Laser-Shield tube was the safest one studied. It had the highest ignition threshold of the four tubes tested.

Reconstruction of the anterior skull base following craniofacial resection

Reconstruction of the anterior skull base (ASB) following craniofacial resection must seal off the cranial cavity from the upper respiratory tract and provide structural support for the brain. The inferiorly based pericranial flap is strong, pliable, and well vascularized and is especially suited for reconstruction of small-to moderate-sized midline defects of the ASB. Surgical technique of pericranial flap reconstruction used in three cases is described. Indications for this flap and other types of reconstruction are discussed and compared. We believe pericranial flap reconstruction of the ASB is technically easy, cosmetically acceptable, and safe.

Primary tracheoesophageal fistula procedure for voice restoration: the University of Texas Medical Branch experience

Voice restoration for laryngectomees is challenging, but in recent years the tracheosophageal (TE) fistula procedure using a one-way valved prosthesis has had relatively good success. The purposes of this study were to determine the success rate for the primary TE fistula procedure, analyze failures, and study methods for selection and training of these patients. In a prospective study, 21 consecutive patients had primary TE fistula procedures performed over an 18-month period. Thirteen of 20 who had adequate follow-up developed fluent, intelligible speech using either duckbill or low-pressure one-way valves. Complications included one stomal infection and one paratracheal fistula. This experience has led to development of a protocol for selection and training of patients for this procedure and to the conclusion that the procedure can improve voice restoration success without an increase in morbidity.

Tumoral calcinosis in the neck

Tumoral calcinosis manifests soft-tissue calcification, usually near major joints. It variably includes hyperphosphatemia, elevated 1,25-dihydroxycalciferol, and an affected sibling. Serum calcium, alkaline phosphatase, and parathyroid hormone are normal. Tumoral calcinosis of the head and neck is very rare, but this diagnosis should be considered when x-ray film of a poorly defined mass shows irregular soft-tissue calcification.

The reporting of statistical techniques in otolaryngology journals

The domain of this study is the reporting of statistical analyses in the otolaryngology literature during 1983 and 1984. Fewer than ten basic statistical procedures accounted for more than 90% of the statistical techniques reported. Implications for authors, journals, and educators are discussed. We offer suggestions for imparting statistical skills that may be helpful in curriculum design, residency training, and continuing medical education planning.

Deep-neck space infections. Diagnosis and management

Deep-neck space infections, which affect soft tissues and fascial compartments of the head and neck, can lead to lethal complications. Eight cases treated over a two-year period were reviewed, and the experience was used to formulate management guidelines. Specific clinical variables analyzed included patient presentation, work-up, treatment, complications, and length of hospital stay. Seven of eight cases required surgery for treatment, one of which was complicated by airway obstruction. Treatment of deep-neck space infections requires knowledge of the natural history of the disease and a detailed understanding of anatomy. Management guidelines include hospitalization, culture and sensitivity tests, antibiotic therapy, diagnostic radiographic procedures, and surgical intervention.

Management of invasive frontoethmoidal sinus mucoceles

Invasive frontoethmoidal sinus mucoceles extending into the anterior cranial fossa or orbits are difficult to manage and can lead to lethal complications. In the past four years, nine cases of frontoethmoidal mucoceles were treated at the University of Texas Medical Branch, Galveston. Five cases were complicated by anterior cranial fossa invasion, orbital invasion, or both. The choice of surgical procedures used to manage these cases depended on mucocele extent and location, which were best determined by computed tomography. Two cases required craniotomy, one of which required an inferior-based pericranial flap for reconstruction of the floor of the anterior cranial fossa. Two cases were managed by osteoplastic flap and fat obliteration procedures. Intranasal drainage was the procedure used in one case that had extensive orbital involvement. Surgical complications included an intracranial abscess in one patient and a cerebrospinal fluid leak in a second patient.

Subrenal capsule assay for squamous cell carcinoma of the head and neck

The murine subrenal capsule assay is an in vivo method for determining the responsiveness of solid tumor xenografts to chemotherapeutic agents. It was used in this study for the purposes of constructing growth curves of squamous cell carcinoma of the head and neck and collecting pilot data on the effects that indomethacin and cisplatin have on this malignant condition. Nine of the ten assays performed were evaluable. Indomethacin, cisplatin, or both were used as treatment drugs in each assay. One-millimeter fragments of viable tumor, from patients with head and neck squamous cell carcinoma, were implanted beneath the renal capsules of normal immunocompetent mice. Baseline and posttreatment measurements were made of the xenografts, and response to treatment was determined by comparing changes in tumor sizes of the test and control groups. Results indicated that reduction in tumor sizes occurred in indomethacin-treated mice in four assays and in cisplatin-treated mice in six assays. In addition, two separate growth curves were calculated by plotting the mean change in tumor size in five mice per day on days 3 through 7. In conclusion, the subrenal capsule assay is a relatively rapid and inexpensive assay in which squamous cell carcinoma remains viable and therapeutic agents can be tested. However, clinical trials that use this assay to choose treatment drugs are needed in order to correlate assay results with clinical responses.

Influence of cisplatin on wound healing--an experimental model

Recent clinical studies have shown that adjuvant chemotherapy may improve response rates to treatment for advanced head and neck carcinomas. Given preoperatively, some chemotherapeutic agents adversely affect wound healing. The specific purpose of this study was to evaluate the influence of cisplatin on wound healing when it is given preoperatively. Forty-four Swiss outbred mice were divided into control and treatment groups. One week before surgery, the treatment group received cisplatin (2 mg/kg body weight) by subcutaneous injections on 2 consecutive days. Each control animal was given an equal volume of normal saline. A 1.5 cm transverse incision was made in each animal, and wounds were closed with surgical staples. The mean wound-breaking strength was determined for a minimum of 5 treatment and 5 control mice on postoperative days 6, 10, 13, and 16. Serum creatinine, blood cell counts, and changes in weight were also monitored. Results showed wound strength on postoperative day 10 to be significantly reduced in mice treated with cisplatin (P less than 0.05). There was no significant difference for wound strength on any other days and all other variables were similar between both groups. In conclusion, cisplatin has an adverse effect on wound healing, the peak of which probably occurs during the proliferative stage of wound healing. Further studies are needed to determine the optimal time for surgery after preoperative chemotherapy. All new chemotherapeutic agents, particularly those being considered in a preoperative regimen, should be tested in this manner.

Tumor responsiveness of squamous cell carcinoma to cisplatin

The addition of chemotherapy to planned multiple modality treatment of patients with advanced head and neck squamous cell carcinomas may improve survival rates, but individual tumor response is unpredictable. An assay for determining tumor responsiveness to specific chemotherapeutic agents would facilitate treatment selection. This study used the subrenal capsule (SRC) assay to test responsiveness of squamous cell carcinoma to cisplatin. Tumor xenografts obtained from ten patients were implanted beneath the renal capsules of control and treatment mice. Tumor responsiveness was determined by using the paired Student's t-test to compare base-line and post-treatment measurements in the cisplatin-treated mice. Results indicated six of ten tumors were sensitive to cisplatin. In conclusion, tumor sensitivity to cisplatin and other drugs may be predictable with the SRC assay, but to be clinically useful, studies will be necessary to correlate assay results with responses observed in patients.

Epithelial-myoepithelial carcinoma of the parotid gland

The EME carcinoma of intercalated duct origin is now recognized as a distinct salivary gland malignancy. A case has been reported that typifies clinical and pathologic features. Both the surgeon and pathologist should learn not only to recognize its dual cellular characteristics, but also to be aware of the potential destructive nature and possibility for metastases with this tumor.

Nasal dermoid with intracranial involvement

Nasal dermoids are unusual lesions resulting from embryopathology. They are diagnosed easily by physical examination. Treatment is complete surgical excision, aided by microsurgical techniques. Involvement of the skullbase is common with "deep-seated" ND, and intracranial involvement is not uncommon. The high-resolution CT scanner is believed to be valuable in diagnosing deep involvement, including intracranial extension. The finding of a bifid crista galli is suggestive of intracranial involvement. Neurosurgical consultation is mandatory for all cases of ND when deep extension is suspected.

Dissemination of computer skills among physicians: the infectious process model

While the potential utility of computer technology to medicine is often acknowledged, little is known as to the best methods to actually teach physicians about computers. The current variability in physician computer fluency implies there is no accepted minimum required level of computer skills for physicians. Special techniques are needed to instill these skills in the physician and measure their effects within the medical profession. This hypothesis is suggested following the development of a specialized course for the new physician. In a population of physicians where medical computing usage was considered nonexistent, intense interest developed the following exposure to a role model having strong credentials in both medicine and computer science. This produced an atmosphere where there was a perceived benefit in being knowledgeable about the medical computer usage. The subsequent increase in computer systems use was the result of the availability of resources and development of computer skills that could be exchanged among the students and faculty. This growth in computer use is described using the parameters of an infectious process model. While other approaches may also be useful, the infectious process model permits the growth of medical computer usage to be quantitatively described, evaluates specific determinants of use patterns, and allows the future growth of computer utilization in medicine to be predicted.