Repair of orbital blowout fractures with Marlex mesh and Gelfilm.

Thirty patients with surgically treated blowout fractures are reviewed. Of these, 3 had Caldwell-Luc procedures with antral packing, 23 had allograft implantation over the orbital floor fracture, and 4 required neither implantation nor antral packing. In 11 patients, with extensive defects, Marlex mesh was employed as the only support. Gelfilm implants were placed in 7 patients with relatively smaller defects. Three patients had Selastic implants and 2 had Mersilene allografts. There were no major complications in any of the 30 patients in the series, and overall results with allograft implants were satisfactory. Properties of the various allografts and indications for their use are discussed.

Vocal cord paralysis resulting from neck injections in the intravenous drug use population.

Intravenous drug use patients present to the head and neck surgeon when injections are directed "in the pocket," or more appropriately, toward the internal jugular vein in the neck. The more common complications of this practice include the development of cellulitis, abscess, and venous thrombophlebitis and, potentially, pulmonary embolism and pseudoaneurysm of the carotid and subclavian arteries. Vocal cord paralysis as a result of neck injection in the intravenous drug-using population is rarely described, and a review of the literature has yielded only two reports addressing this uncommon phenomenon. During a 7 1/2-year period between October 1981 and June 1989, nine patients presented to Detroit Medical Center with hoarseness, upper-airway obstruction, or both following the injection of heroin or related substances into the neck. Otolaryngologic evaluation demonstrated unilateral or bilateral vocal cord paralysis coincident with recent neck injections. The clinical signs and symptoms, location of the injections, acute management, and subsequent complications are catalogued. Acute management of these patients consisted of airway assurance via tracheotomies when indicated and observation for the development of cellulitis, abscess, or more life-threatening neurovascular complications. Follow-up laryngeal examinations ranged from 4 months to 4 1/2 years and found no demonstrable return of vocal cord function in any of the nine patients.

Bacteriology of sinusitis in human immunodeficiency virus-positive patients: implications for management.

The bacteriology of sinusitis in human immunodeficiency virus (HIV)-infected patients has been only sporadically reported. In this study, we report the results of cultures taken from 12 HIV patients with refractory chronic sinusitis who underwent surgery. Nine of the 12 patients had positive cultures with 16 isolates and 5 patients having multiple isolates. Five of the 12 patients grew out atypical or opportunistic infections not responsive to standard medical therapy, including 3 patients with cytomegalovirus, 1 with Aspergillus fumigatus, and 1 with Mycobacterium kansasii. These results suggest the need for aggressive medical care for HIV-infected patients with sinusitis and early intervention for tissue cultures in patients who do not respond to standard antibiotic regimens.

Current status of surgical decompression and drainage procedures upon the endolymphatic system.

At the present time, neither the etiologic factors nor the pathophysiologic mechanisms that lead to the development of endolymphatic hydrops or Ménière's disease are known; however, the anatomic-pathologic alterations in the labyrinth that are produced by the disease are well-documented. Undoubtedly, what is not known is responsible for the controversial status and questionable benefit that surgical decompression and drainage procedures have upon the endolymphatic system.

Evaluation and management of the dizzy patient.

Evaluation and management of the dizzy patient remains frustrating to both the patient and physician. Numerous disorders may induce dizziness; these include not only inner ear disoders but also various central nervous system, ocular, and general systemic disturbances. Since dizziness has many variations, the subtle nuances the symptom may manifest must be explored throughly. Similarly, a consistent approach to the patient's physical and larboratory examination must be taken to understand the pathophysiology of the dizziness. This includes comprehensive auditory and vestibular evaluation, complete neurologic and ophthalmologic examination, and laboratory evaluation for latent or manifest systemic disease. The management of dizziness and vertigo is largely symptomatic. Certain exceptions exist where specific medical and surgical approaches may be beneficial, but the limitations of such treatment must be appreciated.

Multiple primary malignant tumors of the head and neck.

Multiple primary malignant tumors associated with an index cancer in the head and neck are gaining attention as more patients survive their initial primary disease, the longevity of the population at large increases, health care delivery becomes more readily available, and sophisticated diagnostic technology is developed. Forty-four patients with multiple primary cancer in whom the index neoplasm was inthe head and neck are reported. This group comprises 17 per cent of the patients with head and neck cancer treated at the Detroit General Hospital in the last 10 years. Forty-seven per cent of the cancers occurred simultaneously, 10 per cent were synchronous (discovered within six months), and 43 per cent were metachronous (discovered later than six months). Eighty-six per cent of the patients are dead; 75 per cent died within one year after the diagnosis of the secondary primary cancer. Patients with simultaneously occurring malignant tumors appeared to have a somewhat poorer prognosis than those with metachronously occurring tumors. Although the highest incidence of multiple primary malignant tumors occurs in the first year, a consistent high incidence puts the patient with a solitary neoplasm at risk well beyond the three to five years of survival usually considered as "cure." Although no factor other than coincidence has been proved to be involved in the pattern of occurrence of multiple primary neoplasms of different tissues or organs, this study does corroborate other reported data that emphasize that patients with head and neck cancer are at greater risk of developing a second primary malignant tumor in the multicentric vicinity of the original lesion, and in the esophagus and lung than the general population. A program of management and post-treatment surveillance is presented. The potential for new primary malignant neoplasms to develop in the multicentric vicinity of the original lesion and in remote organs cannot be approached with detached curiosity.

Fracture of the frontal sinus in children.

Two juvenile patients, ages 5 and 8, had traumatic fractures of the frontal sinus that included involvement of the nasal-frontal ducts and posterior tables. Principles of management are discussed and the techniques for the operative procedures described. While rare in occurrence in children, it is felt that traumatic involvement of the nasal-frontal ducts or posterior tables of the frontal sinus requires an osteoplastic flap--fat obliteration of the frontal sinus cavity in order to preclude subsequent mucocele development or mucosal ingrowth into the anterior fossa.

Management of acute laryngeal injury: a critical review.

The approach to management of 30 cases of laryngeal trauma coming to open exploration is outlined. Eighteen patients had blunt trauma and 12 had penetrating wounds. Four cases resulted in airway compromise and all were in the blunt trauma group. Although significant granulation tissue response occurred in only eight of 30 cases, it was present in three of the four concluding with stenosis. It is demonstrated that the use of a stent, with a tissue graft, when mucosal approximation cannot be accomplished, facilitates prevention of endolaryngeal distortion and webbing and maintenance of skeletal framework integrity; its use did not predispose to granulation tissue development. A principal etiologic factor in those patients who had good airway but only a fair voice was arytenoid fixation, this despite anatomic reduction when subluxation occurred. Recurrent nerve injury was identified in only one patient. Foremost in management is suspicion and recognition of laryngeal injury in the multiple trauma patient. Once the urgent problems of hemorrhage, shock, and airway are attended to, attention must be directed to a systematic evaluation of the neck and larynx.

Laryngeal injury: a critical review.

Thirty consecutive cases of laryngeal trauma requiring open exploration are reviewed. Eighteen injuries were the result of blunt trauma and 12 resulted from penetrating wounds. Within the blunt trauma group, eight of 18 injuries resulted in a competent airway and a good voice, six with a good airway but a fair voice, and four with airway compromise. Of 12 patients with penetrating wounds, ten sustained a good airway and a good voice, two a good airway and fair voice. Substantial granulation tissue response, though occurring in only eight of the 30 patients, was present in three of the four patients with airway stenosis. The use of a stent, in association with a soft tissue graft when mucosal loss cannot be approximated primarily, does not predispose to such a response, but rather facillitates maintenance of a competent skeletal framework and prevention of soft tissue endolaryngeal distortion.

Airway complications in patients with closed-head injuries.

The neurologic deficits in the closed-head injury population present special problems when managing the airway. Many of these closed-head injury patients require long-term intubation with endotracheal tube or tracheostomy to treat their central respiratory problems and control oral and pulmonary secretions. Four hundred sixty-seven closed-head injury patients were seen over a five-year period. Seventy-two of these patients required long-term endotracheal intubation, tracheostomy, or both. A prospective study by direct endoscopic examination prior to decannulation showed 23 of these 72 patients (32%) had important laryngeal or tracheal findings. The principal abnormalities observed were vocal cord paralysis, tracheal stenosis, subglottic stenosis, glottic stenosis, and tracheomalacia. This study suggests also that severely mentally impaired patients (cognitive function II and III) should retain their tracheostomy because of the high morbidity and mortality among these patients (31%) when they are decannulated. This mortality was directly related to poor pulmonary toilet, with pneumonia and sepsis being the major causes of death. This study did not show that the use of steroids or ventilators in the initial management adversely effected airway complications.

Acute and chronic effects of ammonia burns on the respiratory tract.

Exposure to anhydrous ammonia can result in substantial injury to the respiratory system, eyes, and integument. In this retrospective study, we present the acute and chronic respiratory manifestations in 12 patients exposed to anhydrous ammonia as a result of the same accident. Survivors suffering significant ill effects are separated into two groups according to history and clinical course. One group of patients sustained exposure to high concentrations of ammonia over a short period of time. They manifested upper airway obstruction and required early intubation or tracheostomy. These patients recovered with few pulmonary sequelae and are presently in good pulmonary health. The second group of patients were exposed to lower concentrations of gas over a prolonged period of time and did not manifest upper airway obstruction. In this group of patients, however, significant long-term pulmonary sequelae are manifested.

Laryngeal rhabdomyosarcoma.

Laryngeal rhabdomyosarcomas are very rare, extremely malignant tumors. Approximately half of the reported cases have occurred in children. Diagnosis may be difficult, and adequate biopsy material is crucial in the identification of these lesions. Unil recently, rhabdomyosarcomas carried a dismal prognosis; however, combined treatment with surgery, irradiation, and triple chemotherapy appears to have improved the outlook. This should probably be the treatment for laryngeal rhabdomyosarcomas, and was successfully used in the case reported herein.

Liposarcoma of the tongue.

Liposarcoma is a rare tumor in the head and neck. No previous report of its occurrence in the tongue is found at the time of this writing and this prompts its presentation. Significant in its management is wide surgical excision. Irradiation may be effective in some metastases. Prognosis is best in well differentiated forms.