Analysis of disability resulting from treatment including radical neck dissection or modified neck dissection.

A multiinstitutional study to define the impact of total treatment programs involving radical neck dissection (RND) and modified neck dissection (MND) on patients' permanent disability was undertaken. A total of 243 patient responses were included in the study. Comparative analyses between the treatment groups show no advantage of one surgical operation over the other in returning patients to their pretreatment employment status. Radiation therapy was identified as adding significantly to the patient's permanent disability.

Merkel cell carcinoma.

Merkel cell carcinoma is an unusual primary cutaneous tumor with an aggressive biologic nature. Following surgical treatment, 40% of patients have local recurrences develop, 55% have regional lymph node metastases develop, and 49% have distant metastases develop. We have treated four patients with Merkel cell carcinoma; only one of the four patients was alive and well after 2 years. Two patients died of metastatic disease, one at 11 months following initial treatment and one at 39 months. The fourth patient had a rapid recurrence following initial treatment and is currently in remission following chemotherapy for regional metastases. Recent reports indicate that chemotherapy may be helpful in treating patients with recurrent or metastatic Merkel cell carcinoma.

Cable grafting of the spinal accessory nerve for rehabilitation of shoulder function after radical neck dissection.

From January 1981 through December 1985, 9 patients underwent radical neck dissection with sacrifice of the spinal accessory nerve for removal of metastatic cancer to cervical nodes followed by reconstruction of the spinal accessory nerve utilizing a cable graft from the greater auricular nerve. Shoulder function on the operated side was assessed postoperatively using a subjective questionnaire, objective strength testing, and EMG recordings. The group that had cable grafts of the spinal accessory nerve were compared to a group who had modified radical neck dissection with preservation of the spinal accessory nerve, and to a third group that had classical radical neck dissection with sacrifice of the spinal accessory nerve and no cable graft reconstruction. The group with cable grafts scored in a position intermediate between the modified neck dissection group and the classical radical neck dissection group on subjective and objective testing. Most of the patients with cable grafts demonstrated voluntary motor potentials in the trapezius muscle on postoperative EMG testing. Cable grafting of the spinal accessory nerve sacrificed during radical neck dissection results in improved shoulder function in the postoperative period. Indications and contraindications for the use of this rehabilitative procedure are presented.

Modified supraglottic laryngectomy and resection of lesions of the base of tongue.

Extensive malignant tumors involving the base of tongue and adjacent pharyngeal walls usually require surgical resection combined with radiation therapy and sometimes chemotherapy. Often it is elected to perform a concomitant laryngectomy to prevent chronic aspiration, but not because of tumor extension to the larynx. A new technique allowing preservation of glottic function is described. This involved preservation of the false vocal folds and their surgical closure. The interarytenoid mucosa is preserved. This provides a fistula with a sphincteric function in the interarytenoid area. A permanent tracheostoma is created. This procedure has been used in the treatment of eight patients from April of 1979 to April of 1982. One patient died of sepsis in the early postoperative period. Of the seven evaluable patients, only one experienced significant aspiration postoperatively. All patients achieved adequate phonation. Four patients developed good speech. The remaining three patients have some speech, but are limited in their articulation because of resection of a significant portion of the oral tongue. Three patients are alive and have developed a recurrence. Two patients are alive with recurrent disease and two patients died of their disease. This procedure appears to allow adequate surgical resection of extensive oropharyngeal neoplasms with preservation of the laryngeal functions of phonation and protection of the lower tracheal-bronchial tree.

Congenital fibrosarcoma in the oral cavity. First reported case.

Fibrosarcoma is uncommon in the head and neck and constitutes less than 1% of malignancies and approximately 6% of the soft tissue sarcomas. Congenital fibrosarcomas are characterized by rapid proliferation and frequent local recurrence following excision. Unlike other sarcomas, metastasis is a rare event. The literature contains less than 50 cases of congenital, solitary fibrosarcoma, with none occurring in the oral cavity. This paper describes a unique case of fibrosarcoma in the oral cavity of a neonate. A 12 month follow-up is provided with an analysis of the histopathology including electron microscopy. The spectrum of fibroproliferative lesions in the pediatric patient is reviewed, and the evaluation and treatment modalities applicable to this age group are outlined.

Identification of the motor laryngeal nerves - a new electrical stimulation technique.

Head and neck surgeons are familiar with the technique of identifying motor nerves in the head and neck region by using electrical stimulation especially in the identification of the facial and the spinal accessory nerves. The identification of the motor laryngeal nerves by electrical stimulation intra-operatively has been described; but, the difficulty of visualization of intrinsic laryngeal muscle movement has prevented the wide spread use of this technique. This paper will introduce a simple, safe and reliable method to allow the surgeon to recognize true vocal cord movement while stimulating the recurrent laryngeal nerve. The movement of a two inch 27 gauge needle placed through the cricothyroid membrane into the ipsilateral true vocal cord permits identification of intrinsic laryngeal muscle movement during electrical stimulation of the recurrent laryngeal nerve. This method has been successfully used in confirming conductivity of the laryngeal nerve during thyroid surgery, Zenker's diverticulum surgery, cricotracheal trauma and recurrent nerve neurectomy for spasmodic dysphonia.

Transient paralysis of the diaphragm following radical neck surgery.

We have observed transient diaphragmatic paralysis with high alveolar to arterial oxygen partial pressure difference following radical neck surgery. Patients required supplemental oxygen for maintenance of arterial oxygenation. Patients following radical and neck surgery should be followed with chest roentgenograph to exclude pneumothorax and diaphragmatic paralysis and arterial blood gases in the immediate postoperative period.

Cancer of the scalp.

Carcinomas on the scalp have a tendency to recur following traditional treatment. Their management is often difficult because of the extent of the tumor and the unique anatomy of the area. In order to maximize cure rates for complicated carcinomas, Mohs micrographic surgeons and other surgical specialists have formed interdisciplinary treatment teams. Resection of bone, parotid/facial nerve dissection, and neck dissection are often necessary. Interdisciplinary cooperation in the treatment of skin cancer leads to maximal utilization of expertise and is a major advance in cancer treatment.

Primary vocal rehabilitation using the Blom-Singer and Panje voice prostheses.

Vocal rehabilitation by means of tracheoesophageal puncture and placement of either the Blom-Singer or Panje silicone prosthesis has become a standard method of speech production following total laryngectomy. The same technique has been employed primarily at the time of the laryngectomy by the Department of Otolaryngology-Head and Neck Surgery, Indiana University Medical Center, and our experience with 11 patients undergoing this technique forms the basis for this report. Of the ten patients available for evaluation, all have developed satisfactory prosthetic speech 2-12 weeks following total laryngectomy. Advantages of this technique include the utilization of standard laryngectomy without compromise of oncologic principles, elimination of a second procedure to place the tracheoesophageal puncture, elimination of the nasogastric tube, care in the pharyngeal closure to afford the maximum success of prosthetic speech production, and finally, the psychological boost. Limitations of the technique have been few but relate to limited voicing with postoperative radiotherapy and unrealistic patient expectations.

Congenital tracheoesophageal fistulas in adults.

Congenital tracheoesophageal fistula without esophageal atresia is commonly known as "H" type. This is an extremely rare anomaly in infants and accounts for approximately 1 1/2-4% of all congenital tracheoesophageal malformations. An anomaly should be described by its anatomical defect, not by a number or letter. There are five main anatomical categories with 85-95% being of the esophageal atresia and distal tracheoesophageal fistula type. About 1 1/2% are of the "H" type. Although today tracheoesophageal fistula is a well-recognized entity, a few of the "H" type have passed through the pediatric period without diagnosis. Those undetected fistulas have successfully masqueraded as chronic lung disease of unknown etiology. Congenital "H" type tracheoesophageal fistulas assume an oblique orientation with the growth of the host to adulthood. This helps to explain the difficulty in diagnosis plus the ability of the host to survive to adult life. Treatment is surgical, consisting of simple ligation via cervical or thoracic approach depending upon location. The 12 previously reported cases in the English literature are reviewed, and a 13th case has been added.

Neck dissection: radical or conservative.

Four hundred and forty-five neck dissections for epidermoid carcinoma over a 10-year period are reviewed as to local recurrence of neck disease. Three hundred and forty-seven dissections were radical en bloc procedures and in 98 a modified conservative technique was utilized. Cervical lymph node classification was applied and a comparison made of the two techniques. A review of the anatomy of cervical fascias and the technique of conservative neck dissection is given. Evaluation of this series of cases indicate that the control of local disease in the neck in the N0 and N1 groups is is accomplished as well with conservative dissection as with radical neck dissection. The number of conservative neck dissections for N2 disease was too limited for accurate comparison. There were no conservative neck dissections done for N3 disease. We suggest that conservative neck dissection be utilized for subclinical and N1 disease and that the classic en bloc dissection be reserved for N2 and N3 situations.

Feasibility of low doses of I-131 for thyroid ablation in postsurgical patients with thyroid carcinoma.

The feasibility of using low doses of I-131 (30 mCi) for ablation of thyroid remnants following surgery for papillary and follicular thyroid carcinoma was examined in 21 patients. Six weeks following near-total thyroidectomy and three days following intramuscular thyroid-stimulating hormone (10 IU), patients were given 30 mCi of I-131 and scans were performed 24 to 72 hours later. Remaining thyroid tissue was identifiable in the thyroid bed in 19 patients, and two patients also had evidence of cervical metastases. Patients with metastases received an additional 100 mCi of I-131. Follow-up I-131 scans were performed at nine to 15-month intervals in ten patients who initially received 30 mCi of I-131, and only one patient showed complete ablation of the residual thyroid tissue, whereas the remaining nine patients had persistent uptake of I-131 in the same regions in which the uptake was seen in the initial postoperative scans. One of the nine patients had evidence of a cervical metastasis as well. It is therefore apparent that total or near-total thyroidectomy rarely removes all thyroid tissue and that an "out-patient" dose of I-131 is not adequate for ablation of postoperative thyroid remnants.

Goldenhar syndrome. Associated with submandibular gland hyperplasia and hemihypoplasia of the mobile tongue.

We report of a case of Goldenhar syndrome with submandibular gland hyperplasia and hemihypoplasia of the mobile tongue. This association has not been noted in the literature. A vascular abnormality or hemorrhagic phenomenon occurring during embryogenesis have been proposed as an explanation for the spectrum of defects seen in this syndrome. Congenitae hearing loss, when it occurs in Goldenhar syndrome, is usually unilateral and conductive in nature; however, inner ear defects may be more common than previously recognized.

Modified neck dissection for metastatic testicular carcinoma.

Carcinoma of the testicle is a unique clinicopathologic entity in that an optimistic attitude toward cure can be entertained even in the presence of distant metastasis. Chemotherapy, followed by an aggressive surgical resection of residual disease, can result in eradication of this neoplasm. This tumor is capable of being monitored by the use of serum markers, namely, human chorionic gonadotropin and alpha-fetoprotein. After induction chemotherapy, the transition of elevated serum tumor markers to normal levels suggests that malignant disease has been eliminated or converted to teratoma. Elevated markers indicate persistent or recurrent carcinoma and mandate further chemotherapy. If normalization of tumor markers occurs, any residual mass in the abdomen, chest, or neck should be surgically resected. The otolaryngologist plays a role in the diagnosis and the resection of residual neck disease. Metastatic testicular carcinoma can present as a supraclavicular neck mass and must be considered in the differential diagnosis of a mass in this area. Large residual neck lesions are best removed through the exposure afforded by modified neck dissection.