A phase I/II trial of twice daily irradiation and concurrent chemotherapy for locally advanced squamous cell carcinoma of the head and neck.

PURPOSE: This study was designed to test the toxicity and efficacy of a regimen of twice daily irradiation and concurrent multiagent chemotherapy for patients with locally advanced squamous cell carcinoma of the head and neck. METHODS AND MATERIALS: This was a prospective Phase I/II trial. Patients received 125 cGy b.i.d. to 7000 cGy with a 6 hr interfraction interval. Chemotherapy was given during weeks 1 and 6 of irradiation and consisted of a 5 day infusion of 5-fluorouracil at 600 mg/M2/day and 5 daily injections of cisplatin at 12 mg/M2/day. Two additional cycles of chemotherapy were given after the completion of radiotherapy. RESULTS: Forty-six patients were evaluable: 28 had technically unresectable disease and 18 had resectable tumors. All had Stage III or IV disease: 84% had T3 or T4 primaries while 53% had > or = N2 neck disease. The primary acute toxicity, confluent mucositis, was seen in 74% of patients. Late side effects occurred in four patients. Median follow-up is 36 months (range 25-44 months). Kaplan-Meier estimates of 2-year disease-free survival and overall survival are 65% and 73%, respectively, while 2-year local regional control and distant disease-free survival are 72% and 88%, respectively. Multivariate analysis revealed that resectability and receiving > 2 cycles of chemotherapy significantly influenced local regional control while age < 60 significantly influenced disease-free survival. CONCLUSION: This form of treatment can be delivered safely. The encouraging results have led to the initiation of a Phase III trial comparing this regimen with b.i.d. radiation alone.

Submandibular rhabdomyoma.

A case of recurrent adult rhabdomyoma of the submandibular gland is presented. This is a rare tumor of the skeletal muscle. Approximately 80 cases have been reported. The salient pathologic features are reviewed and a discussion and review of the literature is presented.

Comparative studies of speech processing strategies for cochlear implants.

A wide variety of speech processing strategies for multichannel auditory prostheses were compared in studies of two patients implanted with the UCSF electrode array. Each strategy was evaluated using tests of vowel and consonant confusions, with and without lipreading. Included among the strategies were the compressed analog processor of the present UCSF/Storz prosthesis and a group of interleaved pulses processors in which the amplitudes of nonsimultaneous pulses code the spectral variations of speech. For these patients, each with indications of poor nerve survival, test scores were significantly higher with the interleaved pulses processors. We believe this superior performance was a result of 1. the substantial release from channel interactions provided by nonsimultaneous stimuli and 2. a fast enough rotation among the channels to support adequate temporal and spectral resolution of perceived speech sounds.

Mechanisms of cholesteatoma formation following stapedectomy.

Poststapedectomy cholesteatoma is uncommon. We report a patient with bilateral cholesteatomas, each following an initially successful stapedectomy for conductive hearing loss due to stapedial fixation from otosclerosis. A revision right stapedectomy done in 1972 was complicated 4 years later by prosthesis extrusion and cholesteatoma. An extensive left cholesteatoma occurred 7 years after stapedectomy in 1977 and required a radical mastoidectomy. The etiology of poststapedectomy cholesteatoma in this patient was probably chronic eustachian tube dysfunction and negative middle ear pressures. The initial right cholesteatoma occurred following prosthesis extrusion, which is presumed to have been the portal of entry of squamous epithelium into the middle ear. The later-occurring left poststapedectomy cholesteatoma represented progression of an attic retraction pocket. Both of these complications were likely secondary to negative middle ear pressure. In addition to eustachian tube dysfunction, other proposed etiologies for poststapedectomy cholesteatoma formation include prosthesis extrusion independent of negative middle ear pressure, unrecognized presence of squamous epithelium in an oval window fat graft, an inverted tympanomeatal flap due to improper positioning, and a marginal perforation from a disrupted anulus. Poststapedectomy cholesteatoma is a rare phenomenon, but does occur. The preoperative exclusion of patients with eustachian tube dysfunction and proper surgical techniques should reduce this complication.

Transseptal repair of unilateral choanal atresia.

Unilateral choanal atresia is a congenital problem initially observed by the otolaryngologist as unilateral nasal obstruction. Elective surgical correction can be done using the transnasal, transpalatal, transantral, or transseptal techniques. Two patients underwent this procedure with the transseptal technique. We believe this is a safe, uncomplicated, and reliable technique for the correction of unilateral choanal atresia.

Surgical approaches for pituitary tumors.

Present methods of pituitary surgery had their inception in the late 1890s. The methods of Halsted, Cushing, and Hirsch of the early 1900s have been developed and refined for continued use today. The advent of the operating microscope and microsurgical operative techniques stimulated a renaissance of interest in transsphenoidal methods for resecting pituitary tumors. Various transsphenoidal approaches are in use today, the most popular being the sublabial transseptal method and the intranasal transseptal approach. These tedchniques lend themselves well to the resection of small intrasellar lesions, such as the prolactin-secreting microadenoma.

The rhinologist and the management of pituitary disease.

Since the early days of pituitary surgery, a variety of transnasal approaches have been used to gain access to the sella turcica. Each of these approaches requires crossing the sphenoid sinus, hence the transsphenoidalnoidal designation of these methods. Since the growth and refinement of microsurgery as a distinct surgical discipline, there has been a coincidental maturation of transsphenoidal microsurgical techniques for the management of a variety of pituitary disorders. The present paper reviews the historical events leading to the current methods of transphenoidal pituitary surgery. Detailed descriptions of each method are given, with the advantages and disadvantages of each. The author's method is described and illustrated in a step-by-step manner, and the criteria which determine operability by transsphenoidal versus transfrontal craniotomy are discussed. The advantages which transsphenoidal techniques offer over transfrontal methods are emphasized. The paper deals with pituitary disorders on a clinical and pathological basis. The work-up of pituitary lesions is discussed, with a detailed presentation of the endocrine evaluation. Further emphasis is given to the value of tomography of the sphenosellar complex in planning operative approaches for removal of pituitary lesions, particularly when the lesion is a so-called "microadenoma," producing no obvious expansion nor erosion of the cellar floor. The author's experience in the management of 125 lesions of the pituitary or associated sella turcica is presented and complications are discussed. Because of the relatively brief period of follow-up, no conclusive evidence can be offered regarding cures in the author's series. However, on the basis of reported experience by others working in the same area, one may expect acceptable long-term improvement or cures in selected pituitary lesions operated on by transshpenoidal methods. The team management of pituitary disorders is stressed. In particular, emphasis is given to the contributions which the current day otorhinolaryngologist can make, because of his knowledge and experience in rhinological and microsurgical techniques. There is no other surgical specialty so uniquely qualified to provide operative treatment of pituitary lesions using transsphenoidal surgical pathways.