Access and surgical approach to the isolated intranasal basal cell carcinoma.

Primary intranasal basal cell carcinoma (BCC) is a rare tumour that presents a therapeutic challenge. Here we present two cases illustrating the lateral alarotomy to gain access to an isolated BCC involving only the intranasal lining. Successful intranasal access was achieved in both cases using the alarotomy technique. We also review other methods of repair for the isolated intranasal lining defect. The presentation of intranasal BCC purely as an isolated entity without cutaneous involvement is rare, and our surgical approach via alarotomy allows optimum visibility for tumour resection.

Percutaneous magnetic resonance image-guided biopsy and aspiration in the head and neck.

OBJECTIVE/HYPOTHESIS: To test the hypotheses that 1) magnetic resonance imaging (MRI)-guided biopsy and aspiration with an open 0.2-T system (Magnetom Open, Siemens, Erlangen, Germany) in the head and neck is feasible and successful and 2) procedure times can be sufficiently short to be well tolerated by the patient. METHODS: Sixty-one MRI-guided procedures were performed in 47 patients (ages, 6 mo-88 y) in the head and neck, including the mucosal sites and masticator and parapharyngeal spaces (n = 23), parotid space (n = 6), submandibular space (n = 2), cervical vertebral column/paraspinal tissues (n = 8), skull base (n = 3), larynx or hypopharynx (n = 3), and infrahyoid nodal chains and surrounding tissues (n = 16). A clinical C-arm imaging system was used, supplemented by an in-room radiofrequency-shielded liquid crystal monitor, rapid gradient echo sequences for needle guidance, and MRI-compatible anesthesia, monitoring, and surgical lighting equipment. Tissue sampling included fine-needle aspiration (n = 58) and cutting-needle core biopsy (n = 27), with 24 patients undergoing both procedures. Procedures were evaluated for success of needle placement, procedure time, and complications. RESULTS: Successful needle placement was accomplished in all cases without complication, with tissue sufficient for pathological diagnosis obtained for all but five patients with an average of 2.1 passes per patient. For fine-needle aspiration, average instrument time was 7.8 minutes per pass, and average cutting-needle core biopsy time was 9.2 minutes. CONCLUSIONS: Interactive MRI guidance for needle biopsy and aspiration of deep head and neck lesions is feasible, successful, and safe. Procedure times are sufficiently short to be well tolerated by the patient.

Complications of rhytidectomy in an otolaryngology training program.

OBJECTIVES/HYPOTHESIS: Complications of rhytidectomy have been widely reported in the literature. This study examines the incidence of complications after rhytidectomy in the hands of chief residents under appropriate attending supervision in an otolaryngology-head and neck surgery training program. MATERIALS AND METHODS: The charts of 96 consecutive SMAS rhytidectomy patients were retrospectively reviewed. Patients were selected for surgery from a clinic designed exclusively for cosmetic facial surgery patients. This clinic was run by the otolaryngology chief resident and was supervised by an attending staff surgeon. Most patients elected local anesthesia and sedation administered by the surgical team. Submental liposuction was performed followed by SMAS plication rhytidectomy. RESULTS: Follow-up ranged from 1 to 60 months. Complications included expanding hematoma (1%), temporary facial nerve weakness (3%), pretragal/mastoid skin slough (4.2%), permanent ear numbness (1%), hypertrophic scar (3.1%), wound infection (1%), and dissatisfaction with result (4%). There were no cases of permanent facial nerve injury. CONCLUSION: These complication rates compare favorably with reported rates of larger studies over the past 30 years. These data support the conclusion that rhytidectomy can be performed safely by otolaryngology residents with little morbidity and good patient satisfaction.

Topoisomerase I activity in squamous cell carcinoma of the head and neck.

In recent preclinical and clinical trials, topoisomerase I inhibitors have shown great promise as antitumor agents. These agents are most effective against tumors with high topoisomerase I activity. Therefore, determining topoisomerase I activity in advance may predict response to topoisomerase I inhibitors. Squamous cell carcinoma of the head and neck and normal tissue samples were obtained from 12 patients. Cellular extracts were prepared, and topoisomerase I activity assays were performed. The results suggest that topoisomerase I activity in squamous cell carcinoma of the head and neck is increased approximately sixtyfold compared to normal tissue. Increased activity often correlates with clinical responsiveness; these results predict that topoisomerase I inhibitors should be effective and selective against squamous cell carcinoma of the head and neck.

Metoclopramide enhances the effect of photodynamic therapy on xenografted human squamous cell carcinoma of the head and neck.

OBJECTIVE: Photodynamic therapy (PDT) is a promising new treatment modality for head and neck cancer that is based on the uptake of a systemically administered photosensitizer in tumor tissue and local illumination of the lesion by a high-intensity visible light source, typically a tunable argon-pumped dye laser. We developed a new photosensitizer named silicon phthalocyanine [SiPc(OH) OSi(CH3)2(CH2)3N(CH3)2, abbreviated as SiPc IV], which yields superior PDT responses in vitro and in vivo compared with other clinically used photosensitizers. However, tumor regrowth following SiPc IV-based PDT is still a therapeutic problem. The benzamide derivatives, for example, have been shown to enhance tumor ablation when used during radiotherapy and chemotherapy. Therefore, we used metoclopramide hydrochloride, a benzamide derivative, to evaluate its effects on PDT response. DESIGN: Intradermally injected human squamous cell carcinoma cells were grown to 40 to 80 mm3 in athymic nude mice and irradiated with 675-nm light (75 J/cm2, 75 mW/cm2) 24 hours after the intraperitoneal injection of SiPc IV (1.0 mg/kg). Metoclopramide hydrochloride (2 to 48 mg/kg) was injected intraperitoneally 1 hour before and 24 and 48 hours after irradiation. RESULTS: Tumors exposed to PDT alone showed 80% to 90% tumor regression with regrowth in most animals within 20 days. Tumors treated with metoclopramide hydrochloride (48 mg/kg) plus PDT demonstrated 100% tumor regression without regrowth up to the time of killing (150 days). No observable toxic effects were clinically apparent with the high doses of metoclopramide. CONCLUSIONS: Our results show that administering metoclopramide in combination with PDT may be a promising approach to the management of head and neck cancer.

Effects of tumor necrosis factor alpha and vascular permeability factor on neovascularization of the rabbit ear flap.

OBJECTIVE: The survival of compromised skin flaps depends on neovascularization for their nutrition and metabolic waste removal. Our study investigated the effectiveness of angiogenic factors in accelerating peripheral neovascularization and in increasing skin flap viability. DESIGN: We elevated pedicled dorsal skin flaps on the ears of 23 New Zealand white rabbits, and the vascular pedicle was ligated to achieve partial flap necrosis. Fifteen flaps were treated with 0.1 micrograms/mL vascular permeability factor, and eight flaps were treated with 1.0 micrograms/mL tumor necrosis factor alpha. The ear flaps that were not treated with growth factor functioned in each rabbit as a normal saline control. MAIN OUTCOME MEASURES: The viability of skin flaps was observed visually and was measured by Cartesian planimetry using templates. Neovascularization was documented by microangiography and by histologic analysis of the flaps. RESULTS: Although the angiogenic factors accelerated neovascularization, increased flap survival was demonstrated only in those animals treated with vascular permeability factor that was supplied by an absorbable gelatin sponge. CONCLUSION: This experimental model, despite different levels of controls, contains multiple variables, including the use of an absorbable gelatin sponge, seroma formation, bioactivity of the angiogenic factors, optimal dosages and dosimetry, the need for a "blinded" format, and the validity of the histologic analysis. Additional investigation must be done and the experimental model itself must be improved before these apparently positive results may be accepted as clinically useful.

Options for reconstruction of the pharyngoesophageal defect.

Reconstruction of the circumferential pharyngoesophageal defect and functional rehabilitation of swallowing after cancer ablation remain a challenge for head and neck surgeons. A variety of techniques have been described, four of which have particular merit. The following general guidelines can be utilized when selecting a reconstructive technique. The pectoralis major myocutaneous flap can be used when pharyngeal mucosa remains following cancer resection or by surgeons who do not perform microvascular free tissue transfer to reconstruct circumferential defects. Gastric pull-up should be used if significant extension of tumor into the esophagus is present, oncologically necessitating esophagectomy. Free jejunal flaps are particularly useful in obese patients or patients in whom the lateral cutaneous thigh flap is otherwise contraindicated. The lateral thigh flap gives excellent results, has low morbidity, and causes virtually no functional impairment at the donor site. We believe that it represents state of the art in pharyngoesophageal reconstruction.

Postoperative monitoring and salvage of microvascular free flaps.

We believe that it is essential to closely monitor the viability of any free flap in order to decrease potential morbidity to the patient. A myriad of techniques have been described, many of which appear quite promising; none has been widely accepted. We believe that clinical assessment of an exposed portion of a free flap is the most reliable method of postoperative "surveillance"; however, continuous observation by the surgeon is impractical. Other monitoring techniques, such as laser-Doppler flowmetry, allow nursing personnel to observe the patient in order to alert the surgeon at the first sign of trouble. Adjunctive monitoring techniques are currently imperfect and, in general, expensive. The cost must be measured, however, against the potential loss of a flap and its subsequent consequences. Until an "ideal" monitoring technique becomes available, a combination of some of the techniques described here will enable the surgeon to maximize the chances of salvaging a failing flap.

Metastatic calcification of the true vocal cords as a cause of hoarseness.

Visceral soft tissue calcification is common in patients with end-stage renal disease. However, metastatic calcification of the true vocal cords has not been described. We present a patient with chronic renal failure and hoarseness in whom an exophytic true vocal cord mass was diagnosed as a metastatic calcification.

Development of thrombosis models in the rabbit.

OBJECTIVE: In an effort to decrease the probability of thrombosis at microvascular anastomotic sites, researchers have examined techniques for decreasing the probability of thrombus formation at these sites. Identification of an appropriate animal model that is relatively easy to perform, reliable, and reproducible was attempted in this study. The goal of this study is to provide other investigators with a comparison and critical appraisal of various thrombosis models allowing a more directed selection of models for their own research. DESIGN: A prospective, nonblinded animal study was designed that compared features of thrombosis models previously described in the literature with each other and with a new model (the "tuck" model), herein described. MAIN OUTCOME MEASURES: Ease of dissection, time to thrombosis, and other technical details were recorded. Additionally, validation of clot histologic features in the tuck model was performed. RESULTS: The inversion graft models were found to be the most highly predictable and reliably thrombogenic, although technically quite difficult. The tuck model produces clot analogous to that produced clinically and is easy to perform, although a predictable number of vessels will not thrombose. CONCLUSIONS: The results of this study comparing various animal models of anastomotic thrombosis suggests that the tuck model is the model of choice for most thrombus prevention studies. When predictability of thrombosis is a critical factor, the inversion graft model should be chosen.

Upper eyelid blepharoplasty. A technical comparative analysis.

The purpose of this study was to compare the results of subcuticular closure with a 5-0 polypropylene suture (Prolene) with those of closure with a running 6-0 fast-absorbing catgut approximation in upper eyelid blepharoplasty. A prospective, double-blind study was designed to compare the results of these closures in patients who presented to the Otolaryngology-Head and Neck Surgery Facial Plastic Surgery Clinic, University Hospitals of Cleveland (Ohio). Thirty consecutive patients voluntarily agreed to participate in the study, and all of them had both types of closure performed on their upper eyelids. Twenty of the 30 patients who were originally enrolled in the study complied with our follow-up recommendations, completed the study, and were the basis for this report. At the time of the procedure, a random selection of closure type was made and a variety of outcome measures were recorded, including operative time, minor complications, senior author and patient aesthetic preferences, and postoperative discomfort levels. Based on the aesthetic preferences, we are of the opinion that a running 6-0 fast-absorbing catgut suture may offer some surgeons slightly better results than a subcuticular permanent suture for closure of the upper eyelid blepharoplasty incision. Comparable morbidity was seen with both techniques. No significant differences in postoperative discomfort levels were identified.

Photodynamic therapy of human squamous cell carcinoma in vitro and in xenografts in nude mice.

Photodynamic therapy (PDT) of cancer is an experimental tumor therapy which is based on the combined use of a systematically administered photosensitizer to a tumor-bearing host and local illumination of the lesion by a high-intensity visible light source, typically a tunable argon dye laser. Human squamous cell carcinoma (HSCC) is the most frequently encountered malignancy of the head and neck. In this study, responses of HSCC cells to PDT were examined in in vitro and in vivo systems. In in vitro studies, the HSCC cells showed a positive photodynamic response with Photofrin-II (Pf-II), chloroaluminum phthalocyanine tetrasulfonate (AlPcTS), and a newly synthesized silicon phthalocyanine (SiPc IV). Single cell suspension of HSCC injected subcutaneously on the back of athymic nude mice resulted in a well-circumscribed tumor mass. The animals required a low tumor dose for the successful establishment of a tumor. The tumor was minimally immunogenic and showed neither macroscopic signs of early metastasis to lung, kidney, liver, or spleen nor evidence of surrounding erythema, fluctuation, or tenderness until the late stages of necrosis. Intraperitoneal administration of AlPcTS or SiPc IV to tumor-bearing mice resulted in rapid uptake of the photosensitizers in liver, skin, and tumor tissue. Twenty-four hours following the intraperitoneal administration of AlPcTS or SiPc IV to tumor-bearing animals, the tumor to normal skin ratio of the photosensitizer was 1.6 or 1.5, respectively. Administration of Pf-II (5 mg/kg) to tumor-bearing animals followed 24 hours later by irradiation of the tumor (135 J/cm2, 630 nm light from an argon pumped-dye laser) resulted in greater than 80% ablation in tumor volume 24 hours post-PDT. These characteristics make this tumor model system suitable for PDT studies of human tumor cells in vitro as well as in vivo.

Management of total nasopharyngeal stenosis following UPPP.

UPPP has emerged over the past decade as a surgical procedure to improve or possibly eliminate Obstructive Sleep Apnea. The procedure itself is not uniformly successful and the technique continues to undergo evolution. Most complications occur in the acute post-operative period and are not unusual. Late complications are seen much less frequently: less than 100 cases of severe nasopharyngeal stenosis have been reported. Several authors have previously identified this problem and have published "avoidance strategies" and we recommend that the UPPP surgeon be well aware of these pitfalls and the ways to avoid them. Stenosis repair using pharyngeal flaps should be the primary technique used to correct this problem. The radial forearm free flap provides the surgeon with another technique for repair of acquired nasopharyngeal stenosis in problem cases in which pharyngeal flap procedures have failed. As with any surgery, the surgeon must have a thorough understanding of the wound healing process.

Intraoral-extramaxillary sinus approach for ligation of the maxillary artery: an anatomic study with clinical correlates.

Surgical control of severe epistaxis is usually reserved for cases refractory to more conservative techniques. We present our experience with intraoral ligation of the maxillary artery as it courses through the buccal fat pad before it enters the pterygopalatine fossa and branches posterior to the maxilla. This technique has been found useful in the control of nasal hemorrhage as well as an adjunct to other surgical procedures, such as removal of benign and malignant neoplasms involving the maxilla and paranasal sinuses. This technique was used for ligation of the maxillary artery in 20 patients. The artery was readily identified in some cases, but required more extensive dissection in others; therefore, an anatomic study in 18 preserved and fresh cadaver specimens was undertaken to investigate the variability of the maxillary artery in the region of the buccal fat pad. There appeared to be significant variation in the distance from the buccal mucosal incision site, as well as variation in the relationship to the pterygoid muscles. This relationship to the pterygoids explains the occasional difficulty in locating the artery for ligation. This technique represents a reasonable alternative to the more traditional transantral approach to ligation of the maxillary artery, as long as the surgeon understands the anatomy of the region, its variations, and where the artery may be located if not immediately apparent. No major complications have been experienced.

Artificial reflex arc: a potential solution for chronic aspiration. I. Neck skin stimulation triggering strap muscle contraction in the canine.

Aspiration can occur when the reflex of deglutition occurring in the brain stem is impaired. Surgical procedures involving the airway have so far failed to provide a long-term solution to this problem. Because the sphincteric properties of the larynx could be used to help separate the air from the food passages on a dynamic basis, we present the concept of an artificial reflex are (ARA) in the canine. The afferent limb of this system consists in a cervical cutaneous sensory surface containing the specific biologic sensors for pressure and stretch, subtended by a corresponding sensory nerve, destined to be eventually implanted into the pharynx. The efferent limb picks up the information resulting from the sensor's distention via a frequency modulator and an amplifier, prior to transmitting it to the recurrent laryngeal nerves through monopolar electrodes, resulting in synchronous glottic closure. In order to test this new concept as a pilot study, this principle was applied in three dogs by using an island of cervical skin tubed on itself and the contralateral strap muscles as effector. Inflation of a Foley catheter introduced into the lumen of this tube resulted in synchronous strap muscle contraction, following corresponding increase in the firing frequency in the subtended sensory nerve. The data obtained in this series of experiments should permit further application at the laryngeal level.