Percutaneous dilatational tracheostomy: still a surgical procedure.

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.

Herpes simplex chronic laryngitis and vocal cord lesions in a patient with acquired immunodeficiency syndrome.

Chronic laryngitis in patients with acquired immunodeficiency syndrome may be due to infections or tumors, such as Kaposi's sarcoma and non-Hodgkin's lymphoma. We present what we believe to be the first proven case of herpes simplex virus chronic laryngitis in a man positive for human immunodeficiency virus. Direct laryngoscopy showed leukoplakic lesions on both vocal cords. Biopsy of the lesions showed squamous epithelial cells with the characteristic features of herpes simplex virus, which was confirmed by immunohistochemical stains. We discuss the differential diagnosis of chronic laryngitis in a human immunodeficiency virus infection. Herpes simplex viral infection of the vocal cords should be considered in patients with acquired immunodeficiency syndrome presenting with chronic hoarseness and leukoplakic lesions on direct laryngoscopy, especially with no evidence of Kaposi's sarcoma, tumor, or cytomegaloviral or fungal infection elsewhere. Treatment should be acyclovir, except in the face of acyclovir resistance.

Orbital impalement by a gearshift knob: case report.

Penetrating trauma to the orbit may cause complex injuries involving the bone, globe, and brain. Successful treatment requires a strategic scheme for preoperative assessment and management and a multidisciplinary surgical approach. These principles are demonstrated by report of a motor vehicle accident in which the driver sustained orbital impalement by a gearshift knob.

Occlusion and narrowing of the pharyngeal airway in obstructive sleep apnea: evaluation by ultrafast spoiled GRASS MR imaging.

Morphologic abnormalities of the pharyngeal airway are frequently found in patients with obstructive sleep apnea. These structural alterations in the pharyngeal airway can be detected in awake patients by using rapid imaging techniques. Ten patients with clinically proved obstructive sleep apnea had ultrafast spoiled gradient-recalled acquisition in the steady state (GRASS) MR imaging of the pharyngeal airway to determine the presence of occlusions and/or narrowings. Twelve sequential images were obtained at one midsagittal plane and at eight transverse planes through the pharyngeal airway. The scans were obtained at the rate of one image per 1.04 sec while the patient was breathing quietly. Occlusions or narrowings of the pharyngeal airways were detected on MR images in all patients. The site(s) of the occlusions and the site(s) and extent of the narrowings varied. Six patients had occlusions and four had narrowings of one or more sites. This study shows that ultrafast spoiled GRASS MR imaging can be used to evaluate patients with obstructive sleep apnea during tidal breathing and is useful for determining the presence of occlusions and narrowings of the pharyngeal airway.

Dynamic study of the upper airway with ultrafast spoiled GRASS MR imaging.

Dynamic magnetic resonance (MR) imaging of the upper airway was not possible previously because of poor temporal resolution. Recently, a rapid technique has been developed that provides the means to obtain multiple images at different section locations with sufficient image quality and temporal resolution to allow a comprehensive, dynamic study of the upper airway. The authors describe an ultrafast spoiled GRASS (gradient-recalled acquisition in the steady state) pulse sequence for dynamic studies of the upper airway. The authors believe that this procedure has potential for identifying and characterizing upper airway abnormalities such as nonfixed occlusions and/or narrowings that may exist in patients with obstructive sleep apnea.

1984 Santa Barbara state-of-the-art symposium on otosclerosis. Results, conclusions, consensus.

A state-of-the-art symposium on otosclerosis convened in Santa Barbara, California on Jan 6, 1984. The panel included some of the most distinguished and experienced otosclerosis surgeons in the world, with a collective experience of over 100,000 stapes operations. The purpose of the symposium was to develop guidelines for safe management of otosclerosis and to identify the at-risk patient for surgery. Topics included techniques developed by these surgeons through avoidance, recognition, and correction of technical problems; complications; and errors that lead to poor results. Discussed in order were patient evaluation, performance of surgery, and postoperative care.

Assessment of laryngeal function by digital subtraction laryngography.

The evaluation of vocal cord function can be problematic in the presence of oropharyngeal tumors, hypopharyngeal tumors, and supraglottic lesions and in noncompliant adult and pediatric patients. The use of computer image subtraction techniques coupled with digital fluoroscopy has inherent high-quality resolution that can provide an excellent image of vocal cord symmetry and movement. The use of air as the contrast medium provides the ability to measure the extent of vocal cord excursion as well as the extent of piriform sinus lesions. In addition, it is a noninvasive procedure that requires a minimal imaging exposure time, with the result that the patient undergoes minimal radiation exposure.

Iodine 125 suture implants in the management of advanced tumors in the neck attached to the carotid artery.

Between 1975 and 1982, 38 patients with locally advanced head and neck cancer attached to the carotid artery underwent surgical excision followed by iodine 125 vicryl suture implant in the neck. Most patients had neck masses that were greater than 6 cm and stage IV disease without clinically evident distant metastases. Twelve patients had received no previous therapy while 26 underwent an implant for recurrent disease. The local control rate in the implant volume was 79%. The local and regional control rate in all head and neck sites was 53%. The mean survival was 11 months. The overall complication rate was 26%. There was no significant correlation of local control or complications with the minimum total dose, volume implanted, individual 125I seed strength, or total seed strength. In patients with large masses attached to the carotid artery, surgical resection followed by a 125I implant for residual disease is a viable alternative to resection of the carotid artery.

One day vs. two days of prophylactic antibiotics in patients undergoing major head and neck surgery.

Thirty patients undergoing major head and neck surgery were prospectively randomized to receive moxalactam (30 mg/kg) before surgery and for either 3 or 6 doses total postoperatively. Wound infection criteria were carefully specified and serum drug levels were monitored. Overall infection rate was 3%; the single infection occurred in a patient randomized to the 3 dose protocol. There was no statistically significant difference in infection rates between the two groups. Drug serum levels between the groups did not differ and none of the patients developed significant drug side effects. We conclude that short course prophylaxis is equally effective as more prolonged therapy. Our wound infection rate compares favorably with previous studies and supports the use of moxalactam as a prophylactive antibiotic in major head and neck surgery.

Primary and secondary keratomas of the frontal sinus.

Keratomas in the paranasal sinuses have been described in the world literature with variable frequency and the inaccurate terminology of cholesteatoma. This paper describes an illustrative case and provides a discussion of the etiology and pathology of this disease. Because the pathologic findings are that of a true keratoma, classification of this disease as primary and secondary keratomas is recommended. The classification 1. primary keratoma is recommended for the epidermal cyst of congenital rest origin and 2. secondary keratoma is suggested for epithelial layers and cysts that are secondary to squamous cell implantation or migrations.

Intraoperative iodine 125 implants. Their use in large tumors in the neck attached to the carotid artery.

Twenty-nine patients with large masses attached to the carotid artery underwent surgical resection, preservation of the artery, and intraoperative iodine 125 implantation via an absorbable suture. Eighteen were treated for recurrent neoplasms, having failed prior surgery and/or irradiation therapy. Eleven were treated primarily. With a minimum follow-up of one year, 76% were disease free in the implant volume and 62% were disease free in the entire neck. Distant metastases occurred in 45%. Mean survival was 15 months in the primary group (range, two to 50 months) and 12 months in the recurrent group (range, four to 26 months). This technique shows promise in providing local control without necessity for sacrifice of the carotid artery.

Digital subtraction laryngography.

Digital subtraction laryngography was used to evaluate laryngeal function in 8 patients: 4 with normal larynxes and 4 with laryngeal disease. Subtracted digital images provided a dynamic display of the extent and symmetry of vocal cord excursions and pyriform sinus inflation, and the vocal cord resting position was also clearly depicted. The technical details of digital subtraction laryngography and its application are described.

Suppression of dibutylnitrosamine-induced bladder carcinomas in hamsters by dietary indole.

Effect of dietary indole on the urinary bladder tumorigenesis by chronic dibutylnitrosamine (DBN) treatment was evaluated in hamsters. In the first experiment, in which DBN-water and diet were given ad libitum, dietary indole significantly suppressed bladder tumor incidence. The inhibitory effect was more pronounced in males. In the second experiment, in which consumption of both diet and DBN-water was rigidly controlled by pair-feeding, dietary indole again significantly suppressed bladder tumor incidence; its effect was similar in both males and females. This suppressive effect of indole on bladder tumorigenesis contrasted markedly with its failure to suppress tumors at other sites such as nasal sinuses, trachea, esophagus, and fore-stomach.

Absorption and protein binding of N-2-fluorenylacetamide and its metabolites in the bladder of rabbit.

To assess the reactivity of a bladder carcinogen, the absorption by the rabbit (male New Zealand White) bladder mucosa of N-2-acetylaminofluorene (AAF), N-hydroxy-2-acetyl-aminofluorene (N-OH-AAF), and the N-O-glucuronide of AAF (N-OGI-AAF), as well as binding to the protein and RNA of bladder mucosa, was measured in vivo and in vitro. Mucosal pieces incubated for 3 hours in medium containing a carcinogen demonstrated that the fluorene nucleus of both AAF and N-CH-AAF bound equally with cellular proteins, while N-OGI-AAF binding was lower. In the presence of an excess of beta-glucuronidase, however, N-OGI-AAF showed binding equivalent to its metabolic precursor. After a 3-hour instillation into the bladder lumen of radioactive carcinogens suspended in urine in vivo, transmural absorption of AAF and N-OH-AAF (90%) was substantial, while N-OGI-AAF was absorbed less (55%). The renal excretion during this period varied from 18 to 52% of the instilled radioactivity. There was little reactivity of these carcinogens with the mucosal RNA, both in vivo and in vitro. The metabolism of N-OH-AAF and N-OGI-AAF was such, both in vitro and in vivo, that the acetyl group was not included in the final protein-carcinogen complex in what appeared to be an enzyme reaction.

Effect of pair-feeding of carcinogen on the incidence of bladder tumors in hamsters. Role of indole, age, and sex.

The role of indole in 2-acetylaminofluorene (AAF) bladder tumorigenesis was critically evaluated in hamsters. To avoid the influence of a nutritional factor on the tumor incidence, the animals were pair-fed for 8, 10, and 12 months. Addition of indole to the AAF diet resulted in a higher incidence of bladder tumors in both males and females (P less than 0.05, P less than 0.05). Indole definitely increased the bladder tumor incidence at 8 months (P less than 0.05). Also significantly different was the tumor incidence between males and females irrespective of the diet administered (P less than 0.05). Indole did not alter the urinary output of N-hydroxy-2-acetylaminofluorene (N-OH-AAF) in males.

Heterotopic urinary bladder with a communicating reservoir.

A heterotopic bladder attached to an Ommaya reservoir was transplanted to the back of a syngeneic rat. Following transplantation, the mucosa underwent ischemic necrosis. However, it was rapidly reepithelialized in 2 weeks as a result of spreading of the epithelium originating from the ureterotrigonal region. By light microscopy the regenerated epithelium was indistinguishable from the normal transitional epithelium, and the cannula connecting the reservoir to the bladder remained patent throughout the observation period of 22 weeks. One bladder, when examined at 22 weeks, contained a transitional cell papilloma with squamous metaplasia. Although further study is needed, this model is potentially useful in studies related to bladder carcinogenesis.

Suppressive role of indole on 2-acetylaminofluorene hepatotoxicity.

Indole is known to suppress the hepatotoxicity and carcinogenicity of 2-acetylaminofluorene (AAF) in rats and hamsters. For elucidation of the mechanism of its protective role, 2 experiments were conducted using young male rats. In the 1st experiment, the 24-hr biliary excretion of N-hydroxy-2-acetylaminofluorene (N-OH-AAF)-glucuronide was measured after 2 and 4 weeks of dietary administration of 0.03% AAF with or without 1.6% indole. The amount of [9-14C]N-OH-AAF that was excreted as the glucuronide following a single i.p. injection of [9-14C]AAF was lower after 2 weeks in animals fed AAF and indole, as compared to those fed AAF alone [1.5 +/- 1.2% versus 19.6 +/- 3.6% S.E. (p less than 0.001)]. After 4 weeks of AAF administration without indole, the biliary excretion fell to 4.8 +/- 2.1%. This was also significantly higher than that of the animals fed both AAF and indole [1.8 +/- 1.2% (p less than 0.025)]. The suppressive role of indole on the conjugate excretion was also reflected in a decreased biliary excretion of all [9-14C]AAF metabolites in animals treated with indole alone. In the 2nd experiment, the protective action of indole was assessed by survival following daily i.p. injections of N-OH-AAF and Na2SO4 solution. Na2SO4 increased the hepatotoxicity of N-OH-AAF. Indole suppressed the toxicity of N-OH-AAF even in the presence of Na2SO4. This protective role of indole was partially overcome only when excess sulfate was coadministered. These results indicate that indole suppresses the biliary excretion of the O-glucuronide of N-OHAAF during the initial exposure of the animal to the carcinogen, possibly reflecting decreased N-OH-AAF formation. Indole also modifies the metabolism of AAF FOLLOWING N-hydroxylation, perhaps activating N-OH-AAF, depending upon the concentration of sulfate available.