Laryngocele associated with squamous carcinoma in a 20-year-old nonsmoker.

A laryngocele associated with squamous cell carcinoma of the larynx is reported in a 20-year-old man without a history of smoking. This is the youngest reported case of carcinoma associated with laryngocele in the literature. This association is supported by the patient's young age and his nonsmoking status. However, this case does not appear to support the conclusion that laryngoceles predispose to the development of squamous cell carcinoma. The clinical history supports the tumor obstruction theory, whereby a laryngocele developed from an obstructing carcinoma of the ventricle.

Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea.

A study was conducted to assess oxygenation and respiratory changes on the first and second postoperative nights after uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA). Twelve patients were postoperatively evaluated with 8-hour nocturnal polysomnography on four occasions: (1) PREOP--night before UPPP, (2) POPN1--first postoperative night, (3) POPN2--second postoperative night, and (4) 3MOS--3-month follow-up study. Results demonstrate that apnea index (AI) and respiratory disturbance index (RDI) were significantly improved at 3MOS from PREOP levels: AI (p less than 0.01) and RDI (p less than 0.05). There were no statistical differences from PREOP to POPN1 or POPN2 for AI, RDI, lowest oxyhemoglobin saturation (LSAT), or number of desaturations (#DESAT). One of twelve patients dropped LSAT greater than 10% from PREOP to POPN1 or POPN2 (82% PREOP to 71% POPN2). Patients were grouped by PREOP LSAT greater than or equal to 80% or less than 80%, and the postoperative change in LSAT was evaluated by comparing PREOP to a value averaging POPN1 and POPN2. Patients with LSAT greater than or equal to 80% decreased by 2.6%; patients with LSAT less than 80% improved by 6.2%. This change in LSAT between groups was statistically different (p = 0.02). These data suggest that in the majority of patients, preoperative indices remain unchanged for at least 2 days after surgery, even for patients who demonstrated improvement at 3 months. However, worsening does occur in some patients. On the basis of the results of this study and clinical experience with the postoperative course, a selective management protocol is outlined.

Mucosal leishmaniasis in Brazil.

The clinical diagnosis and laboratory identification of Leishmania braziliensis braziliensis, a parasitic disease affecting the upper aerodigestive tract, is difficult. A retrospective computer-assisted analysis of patient records was done after examination of 58 patients with mucosal leishmaniasis in an endemic area of L. braziliensis braziliensis in Bahia, Brazil during January 1987. Biopsies of clinically active and clinically inactive mucosal patients were examined for parasites using routine hematoxylin and eosin histopathology and a new technique for rapid detection of Leishmania amastigotes using a genus-specific indirect immunofluorescent assay. No amastigotes were found in specimens from seven patients with clinically inactive mucosal disease using immunofluorescent monoclonal assay techniques, whereas specimens from seven out of 14 patients with clinically active mucosal disease were positive. These results suggest that the immunofluorescent antibody technique is markedly superior in identifying the intracellular amastigote in tissue sections of mucosal biopsies when compared to histopathology techniques or with other standard tests done in rural areas of Brazil. Various clinical and laboratory test data of the entire group of patients were examined and the efficacy of treatment evaluated. The median interval of time noted between cutaneous and mucosal disease was 4.5 years. Relapse was noted in 31% of patients treated with a low dose of meglumine antimoniate (10 mg per kg of body weight). Patients treated with a high dose of meglumine antimoniate (20 mg per kg of body weight) had a relapse rate of 27.3%. A chi-square statistical analysis revealed no significant difference (chi 2 = 0.049) between the two groups. Patients were considered cured if mucosal granulations were clinically absent after 4.6 years.

Treatment of blast injury to the ear.

Blast injury to the ear has long been acknowledged as potentially incapacitating. This paper discusses the scope of these injuries in terms of the anatomic and physiologic consequences. Management of both acute and chronic injuries is discussed, with specific regard to the deficits in a patient's functional ability once blast injury has occurred.

Blast injuries of the ear in military operations.

Exposure to blast waves from the explosion of ordnance is a common feature of combat operations. The ear is the organ most sensitive to such strong pressure waves. Blast damage to the ear may range from minor acoustic trauma to major disruption of middle and inner ear structures. Standard hearing protectors should offer a significant degree of shielding from these injuries. Aural injury alone seldom should cause a soldier to abandon a combat mission. However, the potential for a large temporary or permanent neurosensory hearing loss does raise issues about such a soldier's effectiveness on the modern, communication-intensive battlefield. Further research is necessary on mechanisms of injury, protective measures, and the effect of hearing loss on military performance.

Otolaryngic health service support in the airland battle.

The Blast Injuries of the Ear Seminar was conducted to better define the state of knowledge about the medical care and consequences of blast injuries of the ear in battle. The immediate concern of this discussion was the relative importance of the finding of widespread eardrum ruptures in penetrating attacks by shaped charge munitions against the Bradley Fighting Vehicle and the M113 Armored Personnel Carrier. In order to focus on the care of the soldier with such injuries, a brief description of the current medical care and evacuation chain of the US Army, as well as the proposed future evacuation chain in the Airland Battle scenario, will be discussed. Detailed treatment of patients will be discussed in the descriptions from the Quad Service Clinical Data Base regarding wounds of the tympanic membrane. Most blast injuries of the ear would not be considered as incapacitating casualties by the Army Medical Department, except in severe circumstances.

Blast injury of the ear: historical perspective.

Blast injury of the ear is rarely encountered by the practicing otolaryngologist. The recent world literature on this entity is reviewed. Symptoms, patterns of injury, and clinical course are highlighted and should form the basis of management under acute and chronic circumstances.

Aggressive paranasal sinus ossifying fibroma.

Sixty-one cases of an aggressive OF involving the paranasal sinus area are reviewed from the literature. We describe another case of this unusual lesion in an 11-year-old girl. These tumors share a similar radiographic appearance, aggressive clinical behavior, and tendency for recurrence after incomplete treatment. Our experiences show that active OF accurately describes this entity and avoids the confusing histologic nomenclature usually encountered. The head and neck surgeon should be aware of this diagnosis so aggressive en bloc resection can be employed whenever possible.

The tricyclic trimipramine in the treatment of subjective tinnitus.

We examined 26 consecutive patients with subjective tinnitus. All subjects were treated with the tricyclic antidepressant trimipramine in a double-blind study, each subject acting as his own control. All subjects were evaluated with pure tone audiometry, site of lesion testing, and auditory brain stem evoked response. The tinnitus assessment consisted of frequency and intensity matching, the determination of masking levels, and a subjective evaluation of severity. Plasma levels of trimipramine were monitored at regular intervals, and the Zung and Millon inventories were administered at the beginning and end of each study period. Nineteen subjects completed the study. Within the trimipramine group, one reported complete disappearance of his tinnitus, eight reported improvement, three no change, and seven that tinnitus was worse. Within the placebo group, eight reported improvement, seven no change, and four that tinnitus was worse. The natural history of tinnitus is such that what has been observed may reflect the evolution of the disease itself, rather than the effect of treatment. We feel that while tricyclics may not have been shown to be effective, the placebo effect played a significant role in the results obtained.

Incidence of Wharton's duct stenosis in floor of the mouth cancers excised with scalpel or cautery vs CO2 laser.

Surgery of the floor of the mouth (FOM) using a scalpel or cautery has produced stenosis of Wharton's duct, necessitating further surgery because of painful enlargement to the gland or suspected metastasis. The laser has been proposed as an alternative method that might avoid this complication. A retrospective study comparing these excisional techniques was done at Walter Reed Army Medical Center between 1973 and 1983. Of a total of 58 lesions, 35 were T1N0M0 and 23 were T2N0M0 (two synchronous lesions being present). Of 35 lesions excised with a scalpel, 11 had an associated submandibular gland resection. Of the remaining 25, two developed secondary duct stenosis. Of 10 lesions excised with cautery, three had an associated excision of the submandibular gland. Of the remaining seven, two developed stenosis and one required subsequent excision of the gland. Of 12 lesions excised with laser, four developed stenosis and two required subsequent excision of the gland. Laser excision appears to be of no advantage in avoiding further surgery of the submandibular gland. A submandibular gland resection at the time of the original resection of T1N0 or T2N0 cancers of the FOM does not appear warranted.

Oculopharyngeal muscular dystrophy: clinical and histopathologic correlations.

Oculopharyngeal muscular dystrophy is an autosomal dominant myopathy that exhibits the symptoms of progressive dysphagia, with ptosis usually occurring after the age of 40. Literature review of this rare disease reveals a high incidence in the French-Canadian population, as well as in five other ethnic groups. Our article details the clinical history and genealogy of the disease through four generations in a family of English descent. Radiographic studies show a cricopharyngeal bar and aspiration. Results of electron microscopic examination of muscle biopsy specimens from the vastus lateralis and cricopharyngeus muscles confirm a chronic, active, severe, myopathic process that is more pronounced in the cricopharyngeus muscle. The recommended treatment for blepharoptosis and the cricopharyngeus muscle pathosis is discussed.

Multimodality therapy for unresectable squamous cell carcinoma of the head and neck.

Eighteen patients with unresectable Stage III or IV squamous cell carcinoma of the head and neck were treated with induction therapy consisting of sequential methotrexate and 5-fluorouracil. This was followed by full course radiation therapy and radical neck dissection for those with residual neck disease. Those with local control were then treated with vinblastine, bleomycin, and cisplatin (VBP). Although 79% of patients achieved a partial or complete response to chemotherapy, only 50% of patients achieved local control. Marked mucositis limited the dose and schedule of radiation therapy. The methotrexate and 5-fluorouracil combination appears to be too toxic for multimodality therapy of advanced head and neck cancer.

Electronystagmographic findings in long-term low-dose quinine ingestion. A preliminary report.

Seventeen subjects were used in this study to measure the long-term effects of low-dose quinine ingestion as correlated with electronystagmographic (ENG) findings in humans. Four subjects served as controls, nine subjects (low-dose group) drank 52.5 mg of quinine per day, and four subjects (high-dose group) drank 105 mg of quinine per day in commercially prepared tonic water. Only the high-dose group showed transient positional testing abnormalities on ENG. In our experiment, the high-dose group ingested one third of the recommended Food and Drug Administration adult daily oral dose of quinine.

Induction chemotherapy with vinblastine, bleomycin, and cis-diamminedichloroplatinum in squamous cell carcinoma of the head and neck.

The results of induction chemotherapy with vinblastine, bleomycin, and cis-platinum II are reported. No survival advantage was seen when the entire treatment group was compared with an historical control group. Special attention is directed to the meaning of complete response and the potential treatment options and survival advantages of the complete responders subgroup.

Hypothyroidism and wound healing: occurrence after head and neck radiation and surgery.

A retrospective five-year review of patients treated for cancer of the larynx disclosed a high prevalence of hypothyroidism after combined therapy. A total of 29 patients were studied. Seven (24%) of the 29 patients had hypothyroidism develop in the posttreatment period (zero to two years). Two (22%) of the nine patients treated with a combination of surgery and radiation had hypothyroidism develop. An additional ten patients treated with radiation alone remained clinically euthyroid, and no thyroid function tests were performed. Of the five patients who became hypothyroid after treatment with a combination of surgery and radiation, two had fistulae develop that were resistant to intensive local care. They closed promptly after treatment of the hypothyroidism. Of the two patients who had hypothyroidism develop after surgery alone, one had fistulae develop that were resistant to local cae, but responsive to thyroid hormone. These patients should have thyroid function tests done in the early postoperative period, and those found to be hypothyroid should be treated promptly.