Superior sagittal sinus thrombosis after radical neck dissection

Dural sinus thrombosis is a rare, potentially fatal complication of a radical neck dissection. The prognosis can vary from complete recovery to rapid death. Magnetic resonance venography provides an effective, noninvasive diagnosis. The goals of therapy are to decrease intracranial pressure and to lyse the thrombus. Systemic anticoagulation and systemic thrombolytics are controversial therapies. The direct intrasinus infusion of thrombolytic agents is under investigation.

Endoscopic management of a giant cholesterol cyst of the petrous apex

Giant cholesterol cyst (GCC) of the petrous apex is a rare clinical entity. This benign cystic lesion can cause neurologic deficits and vascular compromise by persistent growth and progressive bone destruction. Magnetic resonance imaging studies of GCC show the lesions to be hyperintense on T(1)-weighted sequences with progressively lower signal intensities on the first and second echoes of T(2)-weighted sequences. These findings are relatively specific for GCC, permitting a narrow differential diagnosis. The goal of surgery is to provide adequate drainage with the creation of a permanent fistula. The classic approaches to these lesions are the posterior fossa craniotomy and the middle fossa extradural craniotomy. The translabyrinthine approach provides wide exposure at the expense of cochlear and vestibular function. The transsphenoidal approach provides adequate drainage with hearing preservation and no craniotomy. The endoscopic, endonasal transsphenoidal approach to a 2.5 cm GCC of the petrous apex accomplished complete drainage with the creation of a fistula. Advances in endoscopic technique and instrumentation facilitated the addition of the approach to the surgeon's armamentarium. In selected cases, this approach provides adequate surgical exposure with minimal morbidity.

Pneumolabyrinth: a late complication of stapes surgery

As temporal bone imaging techniques continue to improve, it is likely that we will see an increase in the detection of pneumolabyrinth. Several mechanisms have been proposed to explain how air enters the labyrinth. A small number of authors has reported an association between pneumolabyrinth and temporal bone fractures, perilymphatic fistulae, and displaced stapes prostheses. In this article, we describe a new case of pneumolabyrinth that was seen as a late complication of stapes surgery, and we summarize what is known about this rare condition.

Modulation of odor-induced increases in [Ca(2+)](i) by inhibitors of protein kinases A and C in rat and human olfactory receptor neurons

Protein kinases A and C have been postulated to exert multiple effects on different elements of signal transduction pathways in olfactory receptor neurons. However, little is known about the modulation of olfactory responses by protein kinases in intact olfactory receptor neurons. To further elucidate the details of the modulation of odorant responsiveness by these protein kinases, we investigated the action of two protein kinase inhibitors: H89, an inhibitor of protein kinase A, and N-myristoylated EGF receptor, an inhibitor of protein kinase C, on odorant responsiveness in intact olfactory neurons. We isolated individual olfactory neurons from the adult human and rat olfactory epithelium and measured responses of the isolated cells to odorants or biochemical activators that have been shown to initiate cyclic AMP or inositol 1,4,5-trisphospate production in biochemical preparations. We employed calcium imaging techniques to measure odor-elicited changes in intracellular calcium that occur over several seconds. In human olfactory receptor neurons, the protein kinase A and C inhibitors affected the responses to different sets of odorants. In rats, however, the protein kinase C inhibitor affected responses to all odorants, while the protein kinase A inhibitor had no effect. In both species, the effect of inhibition of protein kinases was to enhance the elevation and block termination of intracellular calcium levels elicited by odorants. Our results show that protein kinases A and C may modulate odorant responses of olfactory neurons by regulating calcium fluxes that occur several seconds after odorant stimulation. The effects of protein kinase C inhibition are different in rat and human olfactory neurons, indicating that species differences are an important consideration when applying data from animal studies to apply to humans.

Vagal paraganglioma: the Jefferson experience

Vagal paraganglioma is a rare tumor of neural crest origin. Although the literature is in agreement with regard to epidemiology, diagnosis, and tumor biology, there is some controversy over treatment modalities for these patients. We performed a nonrandomized retrospective study in a large single-institution series of patients (n = 19) in whom vagal paraganglioma was diagnosed. General statistics included age, male/female ratio, tumor size, and duration of follow-up. Other variables such as signs and symptoms at presentation, family history, multicentricity, metastatic disease, and secretion of catecholamines were included. CT scan, MRI, and angiography were used in combination for diagnostic purposes as well as for treatment planning. Preoperative embolization was performed in 5 of the more recently treated patients. Current issues regarding the use of preoperative embolization and choice of surgical approach were analyzed. In this article the possibility and sequela of vagus nerve-sparing procedures will be presented. Operative complications and postoperative morbidity related to cranial neuropathies will be discussed. The rationale for performing adjunct procedures, including cricopharyngeal myotomy and vocal fold medialization, to facilitate the rehabilitation of patients with postoperative cranial nerve deficits will be given. Our findings and recommendations will be compared with currently accepted treatment protocols in conjunction with a review of the literature.

Leiomyosarcoma of the larynx: diagnosis aided by advances in immunohistochemical staining

We present only the 12th reported case of a laryngeal leiomyosarcoma. This tumor was diagnosed with the aid of the newer immunohistochemical stains on archival paraffin-embedded tissue. The diagnosis and management of these tumors is based largely on the patterns seen in the small number of earlier reported cases of head and neck leiomyosarcomas and laryngeal sarcomas.

Olfactory neuron-specific expression of NeuroD in mouse and human nasal mucosa

Human olfactory neuroepithelium (OE) is situated within the olfactory cleft of the nasal cavity and has the characteristic property of continually regenerating neurons during the lifetime of the individual. This regenerative ability of OE provides a unique model for neuronal differentiation, but little is known about the structure and biology of human olfactory mucosa. Thus, to better understand neurogenesis in human OE, we studied the expression of olfactory marker protein (OMP), TrkB and NeuroD in human nasal biopsies and autopsy specimens and compared these data with those obtained from normal and regenerating mouse OE. We show that NeuroD and TrkB are coordinately expressed in human OE. Thus, by using these markers we have been able to extend the known boundaries of the human OE to include the inferior middle turbinate. In normal mouse OE, TrkB and OMP expression overlap in cells closest to the superficial layer, but TrkB is expressed more strongly in the lower region of this layer. In contrast, NeuroD expression is more basally restricted in a region just above the globose basal cells. These characteristic expression patterns of OMP, TrkB and NeuroD were also observed in the regenerating mouse OE induced by axotomy. These results support a role of NeuroD and brain-derived neurotrophic actor (BDNF), the preferred ligand for TrkB, in the maintenance of the olfactory neuroepithelium in humans and mice.

Clinical impact of sonographically guided biopsy of salivary gland masses and surrounding lymph nodes

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren's-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Clinical disorders of smell and taste

Renewed attention to chemosensory dysfunction has revealed that a substantial portion of the population are affected during their lives, many simply as a result of aging. The authors discuss terminology, assessment, etiology, and prognosis and compare current understanding with that presented by Mackenzie in 1884.

Selectivity and response characteristics of human olfactory neurons

Transduction mechanisms were investigated in human olfactory neurons by determining characteristics of odorant-induced changes in intracellular calcium concentration ([Ca2+]i). Olfactory neurons were freshly isolated from nasal biopsies, allowed to attach to coverslips, and loaded with the calcium-sensitive indicator fura-2. Changes in [Ca2+]i were studied in response to exposure to individual odors, or odorant mixtures composed to distinguish between transduction pathways mediated by adenosine 3'5'-monophosphate (cAMP; mix A) or inositol 1,4,5-trisphosphate (InsP3; mix B). Overall, 52% of biopsies produced one or more odorant-responsive olfactory neurons, whereas 24% of all olfactory neurons tested responded to odorant exposure with a change in [Ca2+]i. As in olfactory neurons from other species, the data suggest that odorant exposure elicited calcium influx via second-messenger pathways involving cAMP or InsP3. Unlike olfactory neurons from other species that have been tested, some human olfactory neurons responded to odorants with decreases in [Ca2+]i. Also in contrast with olfactory neurons from other species, human olfactory neurons were better able to discriminate between odorant mixtures in that no neuron responded to more than one type of odor or mixture. These results suggest the presence of a previously unreported type of olfactory transduction mechanism, and raise the possibility that coding of odor qualities in humans may be accomplished to some degree differently than in other vertebrates, with the olfactory neuron itself making a greater contribution to the discrimination process.

Elapsed radiation therapy treatment time as a predictor of survival in patients with advanced head and neck cancer who receive chemotherapy and radiation therapy

PURPOSE

To determine whether elapsed radiation therapy treatment time relates to survival in patients with head and neck cancer treated sequentially with chemotherapy and radiation therapy.

MATERIALS AND METHODS

From 1981 to 1988, 76 adult patients with bulky stage II-IV head and neck cancer received induction chemotherapy (fluorouracil and cisplatin). Those with a complete or partial response (n = 46) received full-dose definitive radiation therapy (range, 64.0-77.5 Gy; median, 70 Gy). Those with less than a partial response (n = 21) underwent surgery and postoperative radiation therapy (n = 15), palliative radiation therapy (n = 4), or palliative chemotherapy (n = 2). Nine patients refused to undergo radiation therapy after induction chemotherapy.

RESULTS

The 5-year overall survival rates were as follows: 32% in all patients, 38% in patients who underwent chemotherapy and radiation therapy, and 27% in patients who underwent chemotherapy, surgery, and radiation therapy. The number of days between radiation therapy treatments was highly predictive of overall survival. In the groups with treatments less than 55 days apart, 56-65 days apart, and more than 66 days apart, the 5-year survival rates were 56%, 46%, and 15%, respectively (P = .02).

CONCLUSION

The time between radiation therapy treatments is strongly predictive of survival in patients undergoing sequential chemotherapy and radiation therapy. The use of induction chemotherapy does not negate the need to avoid treatment interruptions during definitive radiation therapy.

Induction of differentiation of human olfactory neuroblastoma cells into odorant-responsive cells

Olfactory neuroblastoma is a rare malignancy of the olfactory mucosa that may be derived from the olfactory epithelium. To characterize this tumor, we cultured olfactory neuroblastoma cells in the presence or absence of growth factors (transforming growth factor alpha and basic fibroblast growth factor) known to affect olfactory tissue and assessed their responsiveness to known odorants by measuring changes in intracellular calcium. Untreated cells did not respond to odorants. Basic fibroblast growth factor treatment had cytotoxic effects, and treated cells did not respond to odorants. Transforming growth factor alpha treatment resulted in the induction of odor responsiveness in these cells. Cells responded to odorants at 100 nM to 100 microM concentrations and responded with both increases and decreases in intracellular calcium. Increases in intracellular calcium were mediated by a calcium influx and were reversibly blocked by compounds known to inhibit second messenger pathways in olfactory receptor neurons. The calcium responses of the olfactory neuroblastoma cells were thus specific to the odorants and similar to those found in olfactory receptor neurons. The results support the notion that olfactory neuroblastoma cells may be of olfactory origin and thus they can be used as a model cell line to study human olfaction.

Expression of the human Achaete-scute 1 gene in olfactory neuroblastoma (esthesioneuroblastoma)

Olfactory neuroblastoma (ONB) is a rare neuronal malignancy of the olfactory mucosal. Markers used in the diagnosis of ONB do not distinguish ONB from other neuronal tumors or tumors with neuroendocrine features thus making the diagnosis of ONB difficult. Using a modified RT-PCR technique, we show that the human homologue of the Drosophila achaete-scute gene HASH1 is expressed in 6 primary and one metastatic ONB specimens, whereas Olfactory Marker Protein (OMP) is not. Previous studies have shown that HASH1 is expressed in immature olfactory neurons and is required for their development. OMP, whose function is unknown, is expressed exclusively in mature olfactory neurons. Together, these data suggest that ONB is derived from immature olfactory neurons of neuroectodermal origin. Analysis of RNA expression in primary tumor specimens and in an established cell line make this an ideal system to study olfactory growth and differentiation. Furthermore, these studies represent the first molecular genetic analysis of this rare and unusual neuronal tumor.

Functionally mature olfactory neurons from two anosmic patients with Kallmann syndrome

Patients with Kallmann syndrome (KS) exhibit hypogonadotropic hypogonadism and anosmia [Kallmann et al., Am. J. Mental Def., 48 (1944) 203-236] secondary to failure of gonadotropin-releasing hormone (GnRH)-producing neurons to migrate from the olfactory placode to the brain, and to agenesis of the olfactory bulbs. It has been hypothesized that olfactory neurons (ON) from individuals with KS are immature partly on the basis of studies in animals showing that lack of synaptic connection of ON with the olfactory bulb results in expression of immature ON [Schwob et al., J. Neurosci., 12 (1979) 880-883]. To test this assumption, we obtained olfactory tissue samples from two males diagnosed with KS on the basis of medical history and MRI studies. Both patients were anosmic. The functioning of cells isolated from biopsies taken from the upper middle turbinate and septum was studied by measuring changes in intracellular Ca2+ concentration ([Cai]) using dual excitation fluorescence microscopy. Biopsies from both patients yielded cells that morphologically appeared to be ON. Seven of 16 cells that morphologically resembled ON responded with a change in [Cai] upon stimulation with an odorant mixture. These studies show that at least some ON in KS individuals are functionally mature and suggest that complete development of the olfactory bulbs is not required for differentiation of mature human ON.

Laryngeal pacing as a treatment for vocal fold paralysis

We summarize etiologies of vocal fold paralysis and current treatments. The recent literature involving electrical stimulation of the larynx is reviewed. Four canines were involved in a study to test a new laryngeal pacemaker system. This system was used to stimulate both the lateral cricoarytenoid and thyroarytenoid muscles. The data are taken from two of these canines. One of the goals was to stimulate the paralyzed side of the larynx based on the activity of the normal (nonparalyzed) side of the larynx. The best stimulation parameters for full addition of the paralyzed vocal cord were 3-7 V, pulse duration of 0.5 ms at a frequency of 84-100 Hz. Principles for electrode design and electrophysiologic parameters pertaining to laryngeal pacing are discussed. We believe that unilateral vocal fold paralysis may someday be treated by stimulating the paralyzed lateral cricoarytenoid and thyroarytenoid muscles to move in synchrony with the normal, unparalyzed, lateral cricoarytenoid and thyroarytenoid muscles.

Angiomyolipoma of the nasal cavity: case report and review of the literature

An unusual localization of intranasal angiomyolipoma is described in an adult male patient with no signs of tuberous sclerosis. The lesion was composed of mature fat cells, vascular spaces with lack of elastic tissue, and presence of bundles of mature smooth muscle cells. Antibodies to intermediate filaments revealed presence of vimentin and absence of desmin in both smooth muscle bundles and in vessel walls. A review of the literature has shown that this is only the third reported case of the angiomyolipoma of the nasal cavity, and some important differences between this entity and renal angiomyolipoma are described.

Mechanics of caloric stimulation in a case with a plug in the horizontal semicircular canal

Horizontal eye movements were recorded by electronystagmography in a subject with a plug of granulation tissue in the unilateral horizontal semicircular canal by the room temperature air caloric stimulation. Stimuli were sequentially presented to both ears with the subject supine and prone, keeping the horizontal canal vertical. Caloric stimuli presented to the unplugged ear resulted in a vestibular nystagmus whose slow phase eye velocity (SPEV) was always directed toward the stimulated side when the subject was supine and toward the opposite side when he was prone. In contrast, calorics presented to the horizontal canal plugged ear showed that SPEV was always directed toward the stimulated side, irrespective of whether the subject was supine or prone. Results were consistent with consensus that the caloric responses noted in the horizontal canal plugged ear reflected horizontal canal afferent activity which may correspond to direct effect of temperature on end organs or afferents. The findings imply that a caloric mechanism exists which is independent of the conventionally accepted one involving concection currents within the canal.

Human olfactory neurons respond to odor stimuli with an increase in cytoplasmic Ca2+

The sense of smell allows terrestrial animals to collect information about the chemical nature of their environment through the detection of airborne molecules. In humans smell is believed to play an important role in protecting the organism from environmental hazards such as fire, gas leaks and spoiled food, in determining the flavor of foods, and perhaps in infant-parent bonding. In addition, the study of human olfaction is relevant to a number of medical problems that result in olfactory dysfunction, which can affect nutritional state, and to the study of the etiology of neurodegenerative diseases which manifest themselves in the olfactory epithelium. Although much is known about behavioral aspects of human olfaction, little is understood about the underlying cellular mechanisms in humans. Here we report that viable human olfactory neurons (HON) can be isolated from olfactory tissue biopsies, and we find that HON respond to odorants with an increase in intracellular calcium concentration ([Cai]).

Hyposmia in allergic rhinitis

BACKGROUND

The association between nasal allergy and loss or diminution of smell is frequently alluded to in the literature; however, neither the true prevalence of hyposmia in individuals with allergic rhinitis nor its bases have been established.

METHODS

We assessed olfactory threshold for phenylethyl alcohol in 91 patients with symptoms of allergic rhinitis and 80 nonatopic control subjects. To determine the degree to which nasal congestion contributes to hyposmia in allergic rhinitis, total nasal resistance was measured in 64 of the patients and 72 of the control subjects.

RESULTS

Olfactory thresholds were significantly higher in allergic patients than in control subjects (p < 0.001), with 23.1% of the patients demonstrating a clinically significant smell loss (defined as threshold at or above the 2.5th percentile of control values). Although nasal resistance was significantly higher among patients than among controls (p < 0.001), it was not related to olfactory threshold in either group. Clinical or radiographic evidence of sinusitis or nasal polyps or both in allergy patients was found to be significantly associated with hyposmia (p < 0.006).

CONCLUSIONS

The observed prevalence of hyposmia among patients with allergic rhinitis suggests that this is a major etiologic factor contributing to smell disorders. Sinusitis or nasal polyps or both may underlie many cases of allergy-related hyposmia.

Current national trends in the posttreatment follow-up of patients with squamous cell carcinoma of the head and neck

INTRODUCTION

Follow-up of individuals treated for a primary squamous carcinoma of the upper aerodigestive tract is critical because of the high risk of development of either recurrent disease or a new primary tumor. A mail survey of physicians actively practicing head and neck surgery was undertaken.

MATERIALS AND METHODS

A multiple-choice survey was distributed to 400 members of the American Society for Head and Neck Surgery. Respondents indicated approach to post-treatment follow up.

RESULTS

Surveys were returned from 290 members (73%). Routine monthly follow up is advocated by 73% of respondents during the first postoperative year. Patients are followed every 2 to 3 months in the second postoperative year by 90% of respondents. During postoperative years, 3 to 5 patients are seen every 4 to 6 months by 97% of respondents. All respondents see patients either semiannually or annually for the remainder of their lives. Sixty percent of respondents advocate annual screening chest radiographs, whereas 14% do not order routine chest radiographs. The overwhelming majority of respondents reserve barium swallow and computed tomographic (CT) scans for evaluation of symptomatic patients. Similarly, nuclear imaging is reserved for patients with specific symptoms or abnormal laboratory tests. Blood tests most frequently monitored include complete blood cell count (CBC) (43%), thyroid function test (22%), and liver function test (20%). Follow-up endoscopic evaluation under anesthesia is reserved for symptomatic patients by over 95% of respondents.

CONCLUSION

These data demonstrate that head and neck surgeons rarely use supplemental studies other than chest radiograph during routine follow up. The authors speculate that routine chest radiograph may be valuable in screening for a second primary carcinoma. Techniques to screen for esophageal tumors remain contentious.

Non-oral etiologies of oral malodor and altered chemosensation

A number of non-oral causes for oral malodor have been discussed. Several well documented etiologies for non-oral malodor include renal failure, cirrhosis of the liver, and diabetes mellitus. Each of these conditions has been examined using analytical instrumentation. In addition there appear to be several other metabolic conditions involving enzymatic and transport anomalies (such as trimethylaminuria) which lead to the systemic production of volatile malodors that manifest themselves as halitosis and/or altered chemoreception. Our studies include patients who have been referred to us after being examined by numerous clinical specialists with no identification or relief from their problem. This is due in part to the intermittent nature of many of these problems as well as an apparent lack of knowledge concerning many of these metabolic problems and their relation to oral symptoms.

Severe orbital infection as a complication of orbital fracture

Orbital fractures secondary to blunt trauma, and their complications, have been the subject of numerous reports, with little mention of an association with severe orbital infection. Conversely, studies of severe (postseptal) orbital infections rarely make reference to orbital fractures as being a significant pathogenetic factor. In a retrospective study of 130 orbital infections, three cases of severe orbital infection were identified as being associated with an orbital fracture, and are thus presented. In the literature, only anecdotal reports and inconclusive studies address this problem, and its possible prevention. The consequences of a pathologic communication between the paranasal sinuses and the orbit secondary to blunt facial trauma are discussed, along with recommendations for prophylactic management.

Vagal paragangliomas: a report of nine cases

Vagal paragangliomas are rare tumors of neural crest origin: fewer than 175 cases have been reported in the English literature. This slow-growing tumor occurs most often at the base of the skull in the parapharyngeal space, but may arise anywhere along the course of the vagus nerve and its branches. Nine clinical presentations and the surgical outcome in seven patients with vagal paragangliomas treated at our institution are reported. A review of the literature, emphasizing evaluation and treatment of these potentially fatal neoplasms, is discussed. Surgical removal is the treatment of choice with vagal tumors. Complications related to the ablation or injury of cranial nerves IX, X, XI, and XII are commonly seen. Surgical techniques that may prevent injury to these vital neural structures are outlined. The postoperative treatment of patients with impaired deglutition secondary to multiple cranial neuropathies is discussed.

Lipoinjection for unilateral vocal cord paralysis

Injection of Teflon paste is a commonly accepted procedure to improve the caliber of voice in unilateral vocal cord paralysis. There are several drawbacks to Teflon injection, among them respiratory obstruction (from overinjected Teflon) and unsatisfactory voice quality (Teflon causes stiffness of the vocal folds). This paper is a preliminary report on lipoinjection instead of Teflon injection into a paralyzed vocal fold. Fat appears to impart a soft bulkiness to the injected cord, while allowing it to retain its vibratory qualities. It is autologous material and can be retrieved if excessively overinjected. The fate of autologous fat injected into a paralyzed vocal cord remains unknown. Most of the literature on lipoinjection concerns repairs of depressed scars or breast augmentation. Our longest follow-up has been 12 months. Three patients have had this procedure, and the results appear to be very encouraging.

5-year results of cisplatin and fluorouracil infusion in head and neck cancer

As part of the developmental process for the Head and Neck Intergroup trial of adjuvant chemotherapy for advanced resectable head and neck carcinoma, in 1981 the Radiation Therapy Oncology Group, Philadelphia, Pa, conducted two nonrandomized pilot studies using chemotherapy consisting of three courses of cisplatin and fluorouracil infusion. Chemotherapy was administered prior to surgery in 42 patients (induction) and after surgery in an additional 29 patients (sequential). The populations were roughly comparable with respect to tumor site and stage. Twelve of the 42 patients in the induction group and seven of the 29 in the sequential group are alive and with no evidence of disease at the last reported follow-up. The median survival was 31 months in the sequential group vs 20 months in the induction group. Only two of the 26 patients with less than a complete clinical response following induction chemotherapy are still alive. Twenty-seven of the 42 patients who received induction chemotherapy did not undergo surgery as initially planned. Despite the lack of surgery, at 5 years the survival between the two groups was not significantly different (27% for the induction group vs 23% for the sequential group).

Randomized study of preoperative versus postoperative radiation therapy in advanced head and neck carcinoma: long-term follow-up of RTOG study 73-03

This is a report of a 10-year median follow-up of a randomized, prospective study investigating the optimal sequencing of radiation therapy (RT) in relation to surgery for operable advanced head and neck cancer. In May 1973, the Radiation Therapy Oncology Group (RTOG) began a Phase III study of preoperative radiation therapy (50.0 Gy) versus postoperative radiation therapy (60.0 Gy) for supraglottic larynx and hypopharynx primaries. Of 277 evaluable patients, duration of follow-up is 9-15 years, with 7.6% patients lost to follow-up before 7 years. Loco-regional control was significantly better for 141 postoperative radiation therapy patients than for 136 preoperative radiation therapy patients (p = 0.04), but absolute survival was not affected (p = 0.15). When the analysis was restricted to supraglottic larynx primaries (60 postoperative radiation therapy patients versus 58 preoperative radiation therapy patients), the difference for loco-regional control was highly significant (p = .007), but not for survival (p = 0.18). In considering only supraglottic larynx, 78% of loco-regional failures occurred in the first 2 years. Thirty-one percent (18/58) of preoperative patients failed locally within 2 years versus 18% (11/60) of postoperative patients. After 2 years, distant metastases and second primaries became the predominant failure pattern, especially in postoperative radiation therapy patients. This shift in the late failure pattern along with the increased number of unrelated deaths negated any advantage in absolute survival for postoperative radiation therapy patients. The rates of severe surgical and radiation therapy complications were similar between the two arms. Because of an increased incidence of late distant metastases and secondary primaries, additional therapeutic intervention is required beyond surgery and postoperative irradiation to impact significantly upon survival.

Dietary evaluation of patients with smell and/or taste disorders

The impact of smell and taste disorders on dietary habits and nutritional status has received limited research attention. This paper reports findings obtained from questionnaires and diet records completed by 40 healthy subjects and 118 patients with chemosensory dysfunction. Chemosensory disorders were frequently associated with decreases in food acceptability. Although dietary responses to these dysfunctions varied greatly, patients with distorted or phantom smell and/or taste sensations tended to report weight loss whereas those with simple sensory loss were more likely to report weight gain. Indices derived from diet records did not indicate that either group of patients was at substantial nutritional risk, but food frequency responses and estimates of body mass index were consistent with patient reports of changes in dietary patterns and weight. In addition, marked weight change and aberrant dietary practices were noted in individual patients. Thus, there were indications that chemosensory dysfunction may be associated with nutritionally important dietary alterations.

Surgical quality control in head and neck cancer. Study 73-03 of the Radiation Therapy Oncology Group

The measurement of quality of medical care has always been a topic of concern to physicians and other health care professionals. During an age of increasing competitiveness in the health care environment, the ability to assess accurately the quality of the care delivered has become increasingly important. The head and neck surgeons within the Radiation Therapy Oncology Group have examined this problem and have developed an evaluation tool that was then applied retrospectively in an attempt to evaluate the quality of surgery performed in a randomized study. The analysis of the results suggested that the retrospective approach to surgical quality control is fraught with hazards and is unlikely to fulfill the goals set for it.

Standardization of computer systems for logging operative cases

With the advent of extremely rapid, powerful, compact, and inexpensive microcomputers, a revolution in data manipulation is ongoing. We have customized and used for over two years prepackaged software to track residents' operative experiences in the Department of Otolaryngology at Jefferson Medical College of Thomas Jefferson University, Philadelphia. An attempt is presently being made to develop a similar system that might be utilized by all otolaryngology teaching programs and thus enable the collection and review of residents' operative experiences nationally. A basic, relational database system is proposed for entering resident caseload data and generating reports for periodic review.

Osteoradionecrosis of the head and neck: a case of a clavicular-tracheal fistula secondary to osteoradionecrosis of the sternoclavicular joint

Radiation therapy is an integral part of treatment for head and neck cancer, but its use is not without complications. We describe the first reported sternoclavicular-tracheal fistula resulting from osteoradionecrosis (ORN) at the medial clavicle. This ORN resulted from definitive radiation therapy for a primary pyriform sinus squamous cell carcinoma. The diagnosis of ORN was made by fiberoptic bronchoscopy. The physiologic damage of ORN is based on a compromised blood supply and altered metabolism of bone formation secondary to effects of ionizing radiation. Treatment requires meticulous hygiene, antibiotics, and debridement as conservative therapy. Radical surgery and reconstruction may be indicated in refractory cases. A thorough preirradiation assessment of patients is mandatory to decrease the incidence of radiation-induced ORN.

Effect of urea, glycerol, and mannitol on basilar and labyrinthine arteries

We studied the effect of urea, glycerol, and mannitol on basilar and labyrinthine arteries of dogs in vitro by use of tension recording methods. When the tissue was exposed to urea or glycerol, temporary relaxation of smooth muscles was initially observed, but was followed by gradually increasing contraction. With mannitol, relaxation of the smooth muscles remained stable as long as mannitol existed in the bathing solution. When the specimens were washed with normal Krebs solution after exposure to any of these three substances, large phasic contractions of the smooth muscles were observed. While only theoretical, we propose a possible explanation for the different effects of these three drugs in the improvement of hearing loss that results from Meniere's disease.

Subjective concomitants of motion sickness: quantifying rotation-induced illness in squirrel monkeys

It has been suggested by numerous researchers that the development of conditioned food aversion (CFA) in experimental animals represents the presence of a subjective state of illness. Squirrel monkeys with proven susceptibility to rotation-induced vomiting were given surgical bilateral labyrinthectomies, a procedure known to abolish signs and symptoms of motion sickness in human beings. Postoperatively, labyrinthectomized monkeys neither vomited nor revealed any reduction in food consumption when exposed to provocative rotation. Other samples of monkeys known to be refractory to horizontal rotation and to sinusoidal vertical motion also exhibited little tendency to acquire a conditioned aversion to banana. But monkeys who had sham operations and those who revealed weak-to-strong signs of motion sickness exhibited a marked CFA (significant reduction in food intake). The strength of CFA was much greater when elicited in the test vehicle when compared with response in the home cage. The findings are interpreted as support for a limited application of CFA procedures for inferring the presence of motion-induced nausea and malaise.

Adaptation and habituation of motion-induced vomiting in squirrel monkeys

Nonrestrained adult squirrel monkeys were found to be prolific vomiters when rotated in the horizontal plane for at least 1 h with visual cues available. When multiple daily spins were given, monkeys who vomited early during the first session tended to habituate during subsequent rotations. Subjects who vomited late during the first spin tended to vomit increasingly earlier for several days before the trend reverted to habituation. When a single rotation was continued for up to 8 h, emetic waves occurred with a high probability density for about 2 h, then ceased for many hours with an occasional animal exhibiting isolated emetic episodes. Adaptation effects were transient; when retested beyond a week, most subjects vomited in less time than did inexperienced monkeys on their first exposure to rotation. Attempts to confirm the findings using sinusoidal vertical acceleration were unsuccessful because of failure to induce vomiting using this type of motion.

Combined radiation therapy and surgery in the management of advanced head and neck cancer: final report of study 73-03 of the Radiation Therapy Oncology Group

Between March 1973 and June 1979, patients with advanced operable squamous cell carcinoma of the supraglottic larynx or hypopharynx were randomly allocated to receive either preoperative radiation therapy (5,000 rad) or postoperative radiation therapy (6,000 rad). Patients with oral cavity or oropharynx lesions were randomly assigned either preoperative radiation, postoperative radiation, or definitive radiation therapy (6,500-7,000 rad), with surgery reserved for salvage if residual disease was present 6 weeks after completion of irradiation. Three hundred twenty patients were evaluable with a median follow-up of 60 months. Based on results in 277 patients across all four regions combined, locoregional control was significantly better for patients assigned to receive postoperative radiation therapy (65%) compared with those assigned to receive preoperative radiation therapy (48%, P = 0.04). This was due to a higher rate of both persistent and recurrent local and regional disease in the preoperative group. Survival also showed a trend to be better in the postoperative group (38%) compared with the preoperative group (33%, P = 0.10). Rates of severe surgical and radiation therapy complications were similar overall. Forty-three patients were evaluable for each of the three treatment regimens assigned to patients with oral cavity or oropharynx lesions. Due to the small number of patients available for this portion of the trial, the observed differences for overall survival (4-year percentage 33% overall; 30% preoperative, 36% postoperative, 33% definitive radiation therapy) and for locoregional control (45% overall; 43% preoperative, 52% postoperative, 38% definitive radiation therapy) were not statistically significant. The use of definitive radiation therapy with surgical rescue as an ethically justified alternative treatment for these tumors remains a question for further research.

Teflon paste implant in unilateral vocal cord paralysis: CT characteristics

Laryngeal Teflon paste implants are routinely used to lessen the manifestations of unilateral vocal cord paralysis. Although the Teflon paste is not visible on plain radiography, it is detected on CT as a high density area. Computed tomography may be useful as a baseline study to determine the amount and location of the Teflon paste and also to detect complications such as acute edema, migration of paste, or chronic granuloma formation.

A two-factor model of rotation-induced motion sickness syndrome in squirrel monkeys

Nonrestrained squirrel monkeys were rotated repeatedly in the horizontal plane once per day for preset times or until a vomiting response occurred. Emesis latencies and frequencies were recorded. Some subjects were fed fresh banana immediately before and after each rotation. The amount consumed provided a measure of conditioned food aversion or feeding suppression. A two-factor model of the motion-sickness syndrome was formulated to account for the data. According to the model, appropriate stimulation of the semicircular canals accompanied by visual and proprioceptive stimulation generates two independent physiologic processes or states: an objective emesis and a subjective nausea process. The emesis process is revealed by vomiting responses and the nausea process is inferred from the appearance of conditioned food aversion. Susceptible monkeys (type I) and resistant monkeys (type II) have different emesis processes, but both have similar nausea processes. Refractory monkeys have no well-developed emesis or nausea processes. Time and order characteristics of the motion-sickness syndrome depend on specific interactions of emesis and nausea processes.

Total temporal bone resection for squamous cell carcinoma

Because of unsatisfactory results in treatment of malignant conditions of the temporal bone, a technique for total en bloc resection of the temporal bone and carotid artery was reported by Graham et al. in 1984. The procedure involves resection of the internal carotid artery, cranial nerves VI through XII, and structures adjacent to the temporal bone. Experience with two additional cases led to numerous modifications in the recommended procedure, as reported by Sataloff and Myers. Additional clinical experience with this technique and its complications has resulted in further modification. Additional pitfalls and specific changes in technique from previous reports are discussed in detail, including a new procedure to assure the adequacy of contralateral venous outflow.

Motion-induced sickness following bilateral ablation of area postrema in squirrel monkeys

Using squirrel monkeys as experimental subjects, we reexamined the disputed role of the area postrema (AP) in motion-induced vomiting. After anesthetization, the obex and rhomboid fossa were exposed surgically, and the AP was ablated by thermal coagulation using either a battery cautery or a CO2 microsurgical laser. Sham operations were performed on another sample of monkeys. Two or more weeks after surgery, all animals were given 10 daily 2-hour horizontal rotations at 30 rpm. Every monkey in both the lesions and sham samples vomited on two or more test days. While the vomiting characteristics were modified following ablation of AP, its function is not indispensible for the development of motion sickness in horizontally-rotated squirrel monkeys.

Fibrous dysplasia of the paranasal sinuses

Fibrous dysplasia (FD) of the paranasal sinuses is rare and often presents a diagnostic challenge. It is usually secondary to extension of disease from adjacent bones and is rarely limited to the sinuses. We have described three cases of FD involving the paranasal sinuses, including the first reported case of FD isolated to the sphenoid sinus. A brief update of the clinical aspects, radiographic appearance, diagnosis, and management of craniofacial FD is provided.

Intensification and habituation of experimental motion sickness in squirrel monkeys by repeated horizontal rotation

The aim of this research was to quantify the development of habituation or intensification of experimental motion sickness induced in Bolivian squirrel monkeys by repeated exposures to horizontal rotation. Incidence, frequency, and latency of vomiting responses were recorded from monkeys rotated daily in a transparent testing chamber at 30 rpm for periods of 1 or 2 hours. Data showed that more than half of the subjects revealed habituation in terms of increased latencies for vomiting. Some showed a tendency to vomit increasingly earlier with multiple daily exposures to rotation. The development of habituation and intensification was evident as early as the second day of rotation. The number of emetic episodes per day decreased as a consequence of repeated rotation, but intensification of vomiting frequency did not occur beyond the fifth day.

Factors affecting descending binaural loudness balances as a manifestation of adaptation

Three trained adults with normal hearing were exposed to a continuous 1-kc/s pure tone in both ears simultaneously at 100 db SPL. In the R ear the tone was attenuated at 1 db/sec until it was inaudible. In the L ear the tone was attenuated at 5 db/sec, and S was asked to adjust the loudness in the L ear by pushing and releasing a hand-switch as in Bekesy audiometry in order to maintain so far as possible a binaural loudness match. At every reduction of 10 db in the R ear (i.e., every 10 sec) the SPL to the L ear was measured from the Bekesy-type tracing which yielded binaural loudness match. While there were inter-subject variations, for all Ss the level of the tone in the L ear (5 db/sec) had to be increased above physical equality for equal loudness, indicating the presence of more rapid adaptation in that ear. The disparity in 2 Ss progressed regularly from near zero after 10 sec to 16-17 db after 1 min. For 1 S, a constant disparity of about 6 db existed throughout the session. Binaural loudness balances by this descending method may be considered a manifestation of normal adaptation, confirming a previous report (Harbert and Young, J. Acoust. Soc. Am., 1968, 43, 752-756) for threshold differences produced by various attenuation rates at various suprathreshold starting levels. An analogous ascending procedure with 1 S yielded results susceptible to the same interpretation.

Effects of head and body restraint on experimental motion-induced sickness in squirrel monkeys

Each of 16 Bolivian-phenotype squirrel monkeys of mixed sex had a machine bolt mounted on the skull with acrylic cement; 13 were provided with temporary plaster body casts allowing free movement. With eyes open, all were rotated in the horizontal plane at 30 rpm every other day until vomiting occurred or for a maximum duration of 120 min/spin. Latencies for motion-sickness signs were recorded under three experimental conditions: free movement, torso fixed to an aluminum frame and both torso and head restrained by bolting to the frame. Subsequently, 10 monkeys from this sample were rotated while blindfolded with head and torso immobilized. Results partially confirmed human and animal findings reported by others: reduced mobility was accompanied by a reduction in the incidence and an increase in the latency of motion sickness. The importance of optokinetic input for the generation of motion sickness in this species was clear.