Pharyngogastrostomy for treatment of severe caustic stricture of the pharynx and esophagus.

Four cases of combined pharyngeal and esophageal stricture were managed by pharyngogastrostomy 4 months to 42 years after injury. The stomach was brought up to the neck via the posterior mediastinum after the esophagectomy. A thoracotomy was not used. The results were suprisingly good in 3 patients followed to 3 years. A fourth patient died 6 months after the operation. In those patients benefiting from the operation, regurgitation was minimal when a few precautions were observed. The patients have normal hunger pains and appetite. They are able to eat a full-sized meal. The advantages of stomach compared to colon replacement of the esophagus are discussed.

Rhabdomyosarcoma of the soft palate in three patients with follow-up of longer than ten years.

Rhabdomyosarcoma of the head and neck is a rare childhood neoplasm. Most occur in the orbit, which accounts for the scarcity of papers on modern techniques of treatment of soft palate rhabdomyosarcomas. Only 30 cases of soft palate rhabdomyosarcoma have been reported in recent years and none had long-term follow-up periods (greater than 10 yr). This study reports three cases of pediatric soft palate rhabdomyosarcomas treated with surgery, radiotherapy (two of three), and chemotherapy. The complications that occurred in one patient are discussed.

Pneumocephalus following ventriculoperitoneal shunt. Case report.

The authors describe a case of massive pneumocephalus following ventriculoperitoneal shunting for hydrocephalus. After multiple diagnostic and surgical procedures, congenital defects in the tegmen tympani of both temporal bones were identified as the sources for entry of air. A functioning shunt intermittently established negative intracranial pressure and allowed ingress of air through these abnormalities; when the shunt was occluded, air did not enter the skull, and there was no cerebrospinal fluid leakage. Repair of these middle ear defects prevented further recurrence of pneumocephalus.

Pharyngoesophageal caustic stricture. Treatment by pharyngogastrostomy compared to colon interposition combined with free bowel graft.

Four cases of combined hypopharyngeal and cervical esophageal stricture secondary to caustic ingestion are presented. Although gastropharyngostomy has rarely been used for treatment of patients with caustic stricture of the pharynx and cervical esophagus, we believe that it is a useful procedure and has several advantages over use of the colon. We prefer total esophagectomy and posterior mediastinal transposition of the stomach to the neck followed by gastropharyngostomy in those patients who have minimal stomach involvement.

Intermediate results of 306 recurrent laryngeal nerve sections for spastic dysphonia.

Recurrent laryngeal nerve section for spastic dysphonia was first performed in 1975 because prior forms of treatment had failed. Virtually every patient has had a detailed postoperative follow-up which includes a tape recording and a self-assessment questionnaire. The majority of patients remain free of spasticity at this medium-term follow-up. In some, spasticity recurred with less than preoperative severity. A small percentage of patients have a persistent breathy phonation. The first group is treated with vocal fold lateralization procedure using the CO2 laser; the second, with Teflon. When needed, voice therapy is also given. This paper provides a basis for diagnosis, indications for surgery, primary and secondary surgical techniques, encountered problems, and medium-term follow-up results.

Problems with surgical (RLN section) treatment of spastic dysphonia.

For over a century spastic dysphonia--a disorder of phonation--remained enigmatic and highly resistant to treatment. Recurrent laryngeal nerve surgery provides patients with elimination of their spastic dysphonia symptoms. Maintenance of long-term surgical results has been a problem in some cases. Management of this problem and of problems in the diagnosis and treatment of patients with spastic dysphonia are discussed. The observations and conclusions are based on almost 300 patients examined and/or treated for this disorder.

Surgical correction of the convex vocal cord after Teflon injection.

Teflon injection of paralyzed and bowed vocal cords has been performed since 1962. It has been generally accepted that nothing could be done if an excess is injected or a granuloma reaction within the cord occurs causing an early or late convex cord which projects across the midline. A technique is described to correct such convex cord problems and the results are given for 12 patients for whom corrective surgery was done.

Prevention of major and minor fistulae after laryngectomy.

Every Head and Neck surgeon has special techniques which he uses to get maximum rates of five-year survival and minimum fistula formation, especially major fistula and carotid rupture. The literature reflects a wide variation in the rate of fistula formation. We reviewed the senior author's prior 78 total laryngectomies and noted a fistula rate of 10.3% (6.4% minor fistulae and 3.9% major fistulae). We also reviewed contributing factors and discuss surgical techniques designed to minimize fistula formation.

Subglottic hemangiomas in infants: treatment with CO2 laser.

Subglottic hemangiomas in infants are rare but potentially lethal. Although the majority tend to regress after 12 to 18 months, lethal compromise of the airway is always possible until then. A plethora of treatments have been advocated for subglottic hemangiomas, each with significant morbidity. Eleven consecutive patients have undergone laser resection of subglottic hemangiomas at the University of California, San Francisco. Three infants have been managed without a tracheotomy. If a tracheotomy is required, earlier removal can be achieved with laser resection. No subglottic stenosis or hemorrhage has occurred following laser resection. CO2 laser resection is now the safest and most effective treatment available.

Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-trapdoor flap.

Laryngeal and tracheal stenosis have been refractory to a wide variety of treatments including dilation, stents, or have required major open operation, e.g., laryngofissure with and without skin or mucosal grafts and segmental resection with larynx release. Adequate airway even when achieved was frequently at the expense of voice quality and significant morbidity or mortality. A new highly successful endoscopic technique is described for the treatment of posterior glottic stenosis (apparent bilateral vocal cord paralysis), subglottic stenosis, and tracheal stenosis up to 1 cm thick. The procedure involves the endoscopic use of the CO2 laser, and a micro-trapdoor mucosal flap. Ninety percent of the patients in the group studied obtained an adequate airway with good voice quality and no tracheotomy was required in those patients not already having one. In 19 patients there was no mortality and essentially no morbidity.

Separation of the larynx and trachea for intractable aspiration.

Aspiration becomes an intractable problem for some patients who have lost normal neurological function of the glottis. Over the long term, a cuffed tracheotomy tube is inadequate. Several methods have been developed to relieve this problem surgically. These include the use of muscle flaps, tracheoesophageal anastomosis, and use of an epiglottic flap. In this paper, we discuss these previous surgical attempts to alleviate aspiration and present our own technique, which involves creation of a tracheostome and closure of the larynx at the level of the first tracheal ring. This has been used with success in three patients. we feel this technique is less complex and results in less surgical trauma to the larynx, important factors when dealing with critically ill patients. This technique is theoretically reversible by re-anastomosing the trachea to the cricoid cartilage after excising the first tracheal ring.

CO(2) laser treatment in 244 patients with respiratory papillomas.

OBJECTIVE: Respiratory papillomas (RP) tend to recur and the difficulty in eradicating the disease makes their treatment frustrating. Meticulous CO(2) laser excisions every 2 months has been the most effective treatment to date. This article analyzes the results of this plan in 244 patients with RP in the nose, nasopharynx, pharynx, hypopharynx, larynx, trachea, lung parenchyma, and skin. METHODS: Two hundred forty-four patients with recurrent RP were treated by the senior author with CO(2) laser excisions and, in some cases, podophyllum and alpha interferon. Demographics, initial distribution of papillomas, number of operations performed on each patient, and current results were evaluated. RESULTS: Careful laser excisions of RPs every 2 months achieved "remission" of disease (no visible RP on indirect or often direct laryngoscopy 2 mo after last removal) in 37% of patients, "clearance" of the disease process (no RP clinically apparent for 3 y after last removal) in 6%, and "cure" (no clinical recurrence for 5 y after last removal) in 17%. Juvenile-onset RP tends to follow a more aggressive course than adult-onset RP. Four patients (1.6%) developed malignant transformation of their papillomas. Except for ones in lung parenchyma, RP in areas other than the true vocal cords tend to be cleared faster because aggressive removal does not cause hoarseness. Lung parenchyma RPs are eventually fatal because of pulmonary failure from abscesses and cysts resulting from a lack of effective treatment. CONCLUSION: Frequent and meticulously performed CO(2) laser excisions can achieve significant voice and airway improvement, and some clinical "cures." However, effective antiviral medicines and/or immunologic agents are needed to achieve true cures with elimination of all human papilloma virus 6 and 11 viruses.

Cranial neuropathies in sinus disease.

To study the problem of cranial neuropathies in sinus disease the inpatient experience at the University of California, San Francisco, and San Francisco General Hospitals was reviewed. The incidence of cranial nerve involvement in acute and chronic sinus inflammations was low (8 percent and 4 percent respectively). The incidence in neoplastic disease of the sinuses was considerably higher (32 percent). Cranial neuropathies occurred in inflammatory disease more frequently when associated with mucopyocele, mucormycosis, and orbital cellulitis. In both inflammatory and neoplastic disease, when cranial nerve deficits occurred, there was a high predelication for sphenoid sinus involvement. Several instructive case histories are included. The important anatomy of the cavernous sinus region and of the orbital apex as it pertains to this problem is discussed.

Carbon dioxide laser enucleation of polypoid vocal cords.

Polypoid vocal cords have routinely been treated by endoscopic vocal cord stripping, often-times resulting in prolonged hoarseness postoperatively. Submucosal CO2 laser enucleation of the polypoid tissue, with preservation of a mucosal flap on the medial edge of the cord, has proved to be a valuable improvement. The surgical procedure is described and results are presented which suggest that voice quality is better earlier than is the case after vocal cord stripping.

CO2 laser treatment of oral leukoplakia.

Treatment of oral leukoplakia has been disappointing with the available treatment modalities, because of inaccurate removal and an approximate 30% to 35% rate of recurrence. The CO2 laser has provided a promising new approach in the management of these lesions with very low morbidity and improved control. Twenty-nine patients were treated with the CO2 laser for 38 extensive (from 1 x 1 cm to 6 x 8 cm) intraoral leukoplakic lesions, 28 for cure and one for palliation. Microscopically the lesions varied from hyperkeratosis to carcinoma in situ. Follow-up of these patients ranges from 3 to 10 years, with an average of 5 years. An initial recurrence rate of 10.8% (4/37) was observed, and a 3-year local control rate of 97% after one to two procedures. A malignant transformation rate of 2.6% was encountered. Excellent wound healing and few complications were observed with this treatment approach. Surgical technique and results are reported supporting the advantages of the CO2 laser over conventional modes of treatment in the management of oral leukoplakia.

The endoscopic Teflon keel for posterior and total glottic stenosis.

Most cases of posterior commissure stenosis today result from endotracheal intubation. The problem has been very difficult to repair. Posterior commissure stenosis has been treated by repeated dilations, which do not work, and reconstructive measures by means of laryngofissure to excise the scar followed by the placement of round stents alone or round stents in combination with mucosal or skin grafts. This treatment also fails frequently. Some, but not all, cases have been cured with laser surgery via microdirect laryngoscopy. An endoscopically placed Teflon keel has been useful in the treatment of posterior glottic and total glottic stenosis when laser surgery is not feasible. Nine patients with posterior glottic stenosis, two of whom initially had total glottic stenosis, have undergone placement of the posterior commissure Teflon keel. Six patients had resolution of the stenosis and were decannulated. One required an arytenoidectomy for a fixed cricoarytenoid joint before successful decannulation. Two patients had marked improvement of their laryngeal airway with this approach, but have not yet been decannulated because of fixed cricoarytenoid joints.

Treatment of carcinoma of the vocal cord. A review of 20 years experience.

At the University of California, San Francisco, 323 patients were treated for carcinoma of the vocal cord between January 1956 and December 1975. Patients with early T1 or T2 lesions were treated with radiotherapy or conservative surgery. Patients with T3 or T4 lesions were treated with total laryngectomy, radiation alone, or combined therapy. Of the 247 patients treated with definitive radiotherapy, initial control of the primary lesion was achieved in 100% of T1S, 80% of T1, 52% of T2, and 50% of T3 and T4 lesions. Surgical salvage of radiation failures was 86%, giving ultimate control rates in this group of 100% for T1S, 97% for T1, 91% for T2 and 64% for T3 and T4. Involvement of the anterior commissure did not significantly affect local control or survival rates of the irradiated patients. Voice quality was satisfactory in 95% of controlled patients. Surgery alone was used as the primary treatment modality in 63 patients, with ultimate local control achieved in 75% of T1S, 83% of T1, 85% of T2, 81% of T3 and T4 lesions. Planned combined therapy was successful in 9/13 patients in whom it was used. The overall 3 and 5 year actuarial survival rates were 84% and 77% respectively corresponding determinate survival rates were 90% and 86%.

Randomized surgical adjuvant trial of interferon alfa-n1 in recurrent papillomatosis.

Sixty-six patients with recurrent respiratory papillomatosis of juvenile onset were treated for six months with interferon alfa-n1 (Wellferon) in a randomized crossover trial. Half received interferon alfa-n1 intramuscularly at a dosage of 5 megaunits per square meter daily for 28 days and then thrice weekly for five months, followed by six months of observation. The other half were observed for six months and then treated. Operations were performed every two months to assess disease extent by a scale developed for this purpose. The score for the patients during the first observation period was stable. There was a statistically significant lowering of score in patients receiving interferon alfa-n1 during both periods of drug administration. Eight of 57 patients with assessable airway disease achieved complete remission, as did one additional patient with disease limited to the nasopharynx. No patients achieved complete remission during six months of observation alone. This difference was statistically significant. Patients without tracheostomy were significantly more likely to achieve remission than those with a tracheostomy. The patients who were observed after discontinuation of the drug therapy showed a significant rise in score within four months. Symptoms of toxicity included transient fever, fatigue, nausea, and headache. Elevations in serum aspartate aminotransferase levels occurred in 64% of the patients. There was an inverse correlation between age and the ability to tolerate the medication. The dose studied may be close to the maximum tolerated dose. It appears that interferon alfa-n1 as an adjuvant to routine surgical management is effective in slowing the growth of respiratory papillomas.

Transnasal mucosal flap rotation technique for repair of posterior choanal atresia.

PURPOSE: To describe improved surgical treatment for posterior choanal atresia (PCA) by creating mucosal flaps with the aid of operating microscope, CO(2) laser, self-retaining nasal retractor, and stenting with a flat polytetrafluoroethylene (Teflon) keel. MATERIALS AND METHODS: Retrospective study of 19 patients with PCA, their ages ranging from 6 days to 4 years 4 months at the time of first repair, representing a total of 32 PCA repairs. Four patients had unilateral PCA, and one did not return for follow-up and could not be located. A transnasal microscopic approach uses a myringotomy knife or CO(2) laser to create an anterior mucosal flap; the CO(2) laser is also used to remove any bone plate and to create the posterior flap. The flaps then are rotated into position and are kept separated by a flat Teflon keel instead of a traditional round stent to avoid pressure necrosis. When a stable epithelialized opening (2 x 2 to 3 x 4 mm) is created, it is enlarged by subsequent staged transnasal CO(2) laser submucosal scar excisions with preservation of the overlying mucosa. This creates rotation or sliding flaps to speed healing and prevents circumferential scar contraction. RESULTS: Eighteen patients were re-examined after periods of 3 months to more than 5 years from when their first epithelialized orifice was created with nasal endoscopy to measure the final orifice size. All 18 patients had clinically adequate-to-good bilateral nasal airways at the latest follow-up with an average orifice size of 3 x 5 mm and a range of 2 x 2 to 4 x 10 mm. This "same day surgery" technique with staged procedures provides similar or better patency rates than a single transpalatal approach but with less surgical morbidity. It has a much lower restenosis rate than the transnasal puncture or PCA excision with prolonged round tube stenting and multiple dilation technique.

Postoperative and follow-up studies of spastic dysphonia patients treated by recurrent laryngeal nerve section.

Long-term results of surgical treatment of spastic dysphonia by RLN section are evaluated by means of perceptual psychophysical scaling and by the patients themselves. It is found that a significant reduction in spastic dysphonia symptoms occurs as a result of surgery, and that these results are maintained after long-term follow-up in the majority of patients. These experimental observations are in agreement with the subjective assessment of postsurgical communication by the patients involved in the study.